text:
You are here: Home / Archives for Deformities
Tarsal Coalition – Presentation and Treatment
Tarsal coalition is a congenital abnormality of the foot in which two or more of the tarsal bones are joined by bone, cartilage, or fibrous tissue. Tarsal bones in a normal foot are otherwise separate. More than half of the cases of the tarsal coalition are bilateral.
Tarsal coalition belongs to the category of flatfoot called rigid flatfoot. In this condition, the feet are stiff, angle outward from the leg and lack middle longitudinal arch. In most people, the condition begins before birth and is caused by a gene mutation that affects the cells that produce the tarsal bones. It has an autosomal dominant form of transmission. Though the coalition forms before birth, it is often not discovered until late childhood or adolescence.
There are seven tarsal bones in the foot. The calcaneus, talus, and navicular bones are those most often affected by the tarsal coalition.
The most common sites for a tarsal coalition are between the calcaneus and navicular bone, and between the talus and calcaneus.
Patients usually present during late childhood or adolescence, but presentations in adulthood are known.
Tarsal coalition is estimated to affect 1% people and has a significant male predilection.
The stiffness and stress that tarsal coalitions produce may lead to arthritis over time.
Fibular hemimelia, Nievergelt-Pearlman syndrome, and Apert syndrome are the syndromes associated with tarsal coalition.
Pathophysiology of Tarsal Coalition
Tarsal coalition is inherited in an autosomal dominant fashion with high penetrance.
The normal motion of the subtalar joint during walking involves both rotation and gliding. During the stance phase, the subtalar joint rotates from valgus to varus to compensate for the external rotation of the tibia during this phase. Tarsal coalition restricts the internal rotation and the tarsal joints compensate, with flattening of the foot, loss of arch and a valgus at heel.
This also causes adaptive shortening of the peroneal tendons and reactive peroneal spasm. That is why the tarsal coalition is also called peroneal spastic flatfoot.
Pain associated with tarsal coalition may be due to ligament sprain, peroneal muscle spasm, surrounding tissue irritation, and degenerative changes.
Most of the tarsal coalitions are either calcaneonavicular or talocalcaneal, each contributing to almost 45% of the cases. Calcaneocuboid, talonavicular, cubonavicular coalitions are much much less common.
Calcaneonavicular usually involves the anterior process of the calcaneus whereas talocalcaneal involves the middle facet.
Ossification pattern of the coalitions is as follow
Calcaneonavicular 8-12 years
Talocalcaneal 12-16 years.
Talonavicular 3-5 years;
Loss of subtalar motion and valgus position of the hindfoot is more apparent as the coalition ossifies. Talocalcaneal coalitions are associated with the greatest loss of subtalar motion and are the most likely to generate valgus as they involve middle facet of calcaneum.
Presentation of Tarsal Coalition
Many tarsal coalitions are asymptomatic and never discovered. The presenting age is usually adolescence mostly though presentation in adulthood is also known.
The main complaint is vague deep pain below ankle around the middle or back half of the foot.
The patient also may present with recurrent sprains as a rigid, flat foot roll the ankle more than normal on uneven surfaces resulting in sprains.
The pain gets better with rest but worsens with activity. The limp may or may not be present.
On examination, there may be tenderness in the region of sinus tarsi in the calcaneonavicular coalition. In cases of talonavicular coalitions, the tenderness is generally just anterior to the medial malleolus.
Heel Tip Test
This test is done to evaluate the loss of subtalar motion.
In this, the examiner supinates the foot of a standing patient by raising the medial border of the forefoot and keeping the heel and lateral border in contact with the floor. When supination of the weight-bearing foot generates only a limited external rotation of the tibia [Notes by rotation of patella outwards] , tarsal pathology must be assumed.
Jack Toe-Raise Test
Jack toe-raise test also demonstrates the fixed nature of the pes planus and the loss of hindfoot inversion.
It is also called Hubscher maneuver. The test is performed with the patient weight bearing, with the foot flat on the ground, while the clinician dorsiflexes the great toe and watches for an increasing convexity of the arches of the foot. Rigid flat foot lacks the arch formation.
Malignancies
Rheumatologic pain
Fractures about the subtalar joint
Not required for diagnosis
Plain x-ray films are usually the first investigation of choice, and in many instances of a bony coalition, especially where there is a large bony bar and the medullary cavity is seen in continuity between the two bones. In fibrous coalitions, there is irregularity and narrowing of the bony interfaces and there is associated sclerosis usually.
A calcaneonavicular coalition is best seen on an oblique film. It usually involves the middle facet.
The calcaneonavicular coalition is suggested by anteater nose sign due to an elongated anterior calcaneal process. It may be present in children of 9 years and above.
Here is x-ray showing anteater nose sign, followed by anteater animal
Anteater Nose Sign, Image Credit: Gentili
The talocalcaneal coalition is best seen on the lateral view. It shows talar beak sign due to impaired subtalar movement, and C-sign of Lateur where C-shaped line or ring around the dome of the talus and the inferior outline of the sustentaculum tali, is considered pathognomonic for subtalar coalition by some but studies differ on sensitivity and specificity of the sign.
C Sign, Image Credit: Pubmed Central
Talar Beaking, Image Credit: Learning Radiology
CT scans have become the gold standard in the evaluation of tarsal coalitions.
MRI is also very good in the identification of tarsal coalitions and distinguishes between bony, fibrous and cartilaginous coalition. It also helps to identify medullary continuity between two bones.
Treatment of Tarsal Coalition
Soft shoe inserts/arch support/toeball pads
The trial of walking cast immobilization with the hindfoot in a neutral position for 3-6 weeks.
Wear proper footwear – i.e.Shoes with a wide toe box and shoes with cushion
Oral anti-inflammatory medication like NSAIDs
Physical therapy – stretch exercises
Local corticosteroid injection – Provide temporary relief
Conservative treatment is more effective in the talonavicular coalition than calcaneonavicular. Most of the cases with calcaneonavicular coalition require surgery.
Tarsal Coalition Surgery
The choice of surgery depends on depends on the patient age, size, type and location of coalition, type of coalition, presence of a flat foot, and presence of arthritis.
Options available for surgery are
Removal of the Tarsal Coalition with or without corrective surgery for a flat foot
Given the ease and relatively good results of surgical treatment, coalition resection prior to the onset of arthritic changes has become more commonly indicated. Larger, more severe coalitions that cause significant deformity and also involve arthritis may be treated with joint fusion. The goal of fusion is to limit movement of painful joints and place the bones in the proper position. Infusion for tarsal coalition, the bones may be held in place with large screws, pins, or screw-and-plate devices.
Removal of the Tarsal Coalition
The surgery involves simply removing the abnormal tissue to allow motion of the back part of the foot. A soft tissue spacer, such as fat or tendon, is placed at removed coalition site to limit bone re-growth. This surgery preserves the rearfoot joints. It does not specifically correct any structural malalignment.
Removal of the Tarsal Coalition with Flat foot Corrective Surgery
This surgery involves removing the abnormal coalition and correcting the flatfoot in a single operation. The goal is to remove the restriction of motion and structurally realign the foot, so that the foot may function in an improved position.
Patients with extensive or multiple coalitions typically undergo fusion procedures, and those with less extensive or isolated coalitions undergo resection and soft-tissue interposition of their coalitions.
Note: Coalition resection is contraindicated when significant degenerative change is present in the joints adjacent to the coalition. Arthrodesis is preferable in such cases.
Arthrodesis is indicated in severe cases with large coalitions, significant arthritis of the foot, and/or a badly maligned foot. The main benefit of this surgery is that it allows for the foot to be realigned. But it is done at the cost of joint motion which may result in compensational ankle and foot problems.
Arthrodesis is a surgical fusion between two or more bones. The procedure is done by removing the cartilage.
Two types of fusions are commonly used to treat tarsal coalitions.
Subtalar arthrodesis
Subtalar arthrodesis fuses the talus to the calcaneus. It is commonly used to treat the talocalcaneal coalition that is too advanced to consider an excision. This arthrodesis affects subtalar joint motion only and is done when the joints in the rest of the foot have not undergone arthritic changes.
Triple arthrodesis
It fuses the calcaneus, the navicular and the cuboid bones. This type of arthrodesis is commonly used to treat any tarsal coalition that is too advanced to consider an excision and the condition has affected other joints in the foot. This type of arthrodesis is commonly recommended in the older patient. It may also be recommended if an excision has been tried and failed to relieve pain.
Filed Under: Deformities, Non Traumatic
Blount Disease – Presentation & Treatment
Blount disease, also termed as tibia vara is characterized by disordered endochondral ossification of the medial part of the proximal tibial physis. Though it is called tibia vara, actual deformities are multiplanar – tibia with varus, procurvatum (a deformity where the apex of angulation is anterior), and internal rotation. It is named after Walter Putnam Blount, an American pediatric surgeon.
Blount disease can lead to a progressive deformity with gait problems, limb-length discrepancy, and early degenerative arthritis of the knee. Deformities of the distal femur may also be present. A predisposition for obese black children and children of Scandinavian descent has been noted.
Types of Blount Disease
There are mainly two types of Blount disease
Early-onset or infantile – Limb deformity develops before age of 4 years
Late-onset – Limb deformity develops after the age of four years.
Late-onset Blount disease is further divided into juvenile type (4-10 years) and an adolescent type (>10 years).
Bilateral involvement is common in Blount disease, particularly with an early-onset presentation.
Langenskiold Classification of Blount disease
Langenskiold in 1952 described six progressive stages visible MRI stages for the infantile type of Blount disease. This classification is based on different degrees of epiphyseal depression and metaphyseal fragmentation of the proximal medial tibial epiphysis.
Stage I
Medio-distal beaking of the upper proximal tibial metaphysis.
Stage II
Wedging of the medial part of the upper tibial epiphyseal secondary ossification center plus a saucer-shaped defect of the upper surface of the metaphyseal beak due to its dissolution, fragmentation & collapse.
Stage III
Stepping of the infero-medial border of the secondary ossification center but without extending distally to the physeal plate level plus deepening of the metaphyseal saucer into a step in the medial metaphysis.
Stage IV
The epiphyseal secondary ossification center passes more distally and crosses distal to the physeal level to fill the metaphyseal step.
Stage V
Separation of the most medial part of the ossification center from the bulk of the secondary ossification center and resides now in the depth of the metaphyseal step below the physis. This is radiologically expressed as either a horizontal cleft (double epiphysis) or complete absence of the medial secondary ossification center as it will be overshadowed by the upper medial tibial metaphysis.
Stage VI
Medial epiphyseal plate closure with a bony bridge.
Etiology and Pathogenesis
The cause of Blount disease is not known and a combination of hereditary and developmental factors has been suggested. It has been found that Blount disease occurs more in children who start walking at an early age and those who are overweight. Therefore, mechanical causes have been suggested to be responsible. The excessive mechanical force at the medial portion of the proximal tibial epiphysis which is still cartilaginous leads to change in the structure and function of the chondrocytes and delayed ossification of the epiphysis.
An obese child with large thighs cannot adduct the hips properly and this produces a varus moment on the knees [fat-thigh gait] thus increasing pressure at the medial part of the proximal tibial physis.
Childhood obesity has also been found to reduce bone mineral content which may further predispose to the development of progressive deformities with increasing weight.
However, mechanical theory alone cannot explain the occurrence of disease only on one side or asymmetrical severity. Therefore, it is suggested that Blount disease may have a genetic predisposition as well.
Many authors believe that disease progression is the result of this cycle of growth disturbance, varus deformity, and further growth disturbance.
Presentation of Blount Disease
Early onset disease presents with varus deformity of the tibia and internal tibial torsion. The disease is usually present on both sides.
In early Blount disease, distinguishing the disease from physiologic bowing, though difficult, is important as varus knees is a very common finding in these children.
Children generally do not report pain, although they can present with a significant deformity. The metaphyseal prominence, or beak, may be palpable over the medial aspect of the proximal tibial condyle.
In contrast, patients with adolescent Blount disease often report pain at the medial aspect of the knee. These patients are typically overweight or obese. In contrast to the early-onset form of the disease, involvement is more commonly unilateral and patients also often have abnormalities of the distal femur.
Laboratory studies have not been shown to aid in the diagnosis of Blount disease.
Plain Radiographs
Radiographs of the knee are critical in assessing and staging the severity of the deformity in Blount disease. A standing full-length anteroposterior radiograph of the entire length of both lower extremities with the patellae forward is crucial for a detailed evaluation of the deformity.
Xray of Bilateral Blount Disease
characteristic changes associated with Blount disease include
Medial beaking of the epiphysis
Widened irregular medial physis
Sharp varus angulation of the metaphysis
Irregular ossification
Medial slope of the epiphysis and metaphysis in varus.
In addition to the Langenskiöld classification, the following measurements are used to differentiate Blount disease from physiologic tibia vara.
Tibiofemoral Angle
The angle between a line drawn from the center of the hip to the center of the knee and a line drawn from the center of the knee to the center of the ankle. The severity of the varus deformity is based on the tibiofemoral angle as measured on standing hip-to-ankle anteroposterior radiographs. The metaphyseal-epiphyseal angle is the angle formed by the intersection of a line through the transverse plane of the proximal tibia epiphysis with a line through the transverse plane of the metaphysis.
Metaphyseal-Diaphyseal Angle
The angle between a line drawn through the most distal aspects of the medial and lateral beaks of the proximal tibial metaphysis and a line perpendicular to a line drawn along the lateral aspect of the tibial diaphysis.
>16 ° is considered abnormal and has a 95% chance of progression
<10 ° has a 95% chance of natural resolution of the bowing
Femoral Metaphyseal-Diaphyseal Angle
The angle between a line drawn perpendicular to the anatomic axis of the femur and a line drawn parallel to the distal femoral physis.
Epiphyseal Metaphyseal Angle
The angle between a line drawn through the proximal tibial physis, parallel to the base of the epiphyseal ossification center, and a line connecting the midpoint of the base of the epiphyseal ossification center with the most distal point on the medial beak of the proximal tibial metaphysis.
Percentage Deformity of Tibia
The percentage deformity of the tibia is calculated as the degree of tibial varus (the medial angle between the mechanical axis of the tibia and a line drawn parallel to the distal femoral condyles) divided by the total amount of limb varus (femoral varus [FV] + tibial varus [TV]). Femoral varus is represented by the medial angle between the mechanical axis of the femur and a line parallel to the distal femoral condyles.
In adolescents, approximately one-third of the varus deformity in adolescents with late-onset disease may be attributable to the distal part of the femur.
MRI can define intra-articular changes such as posteromedial depression of the tibial plateau and hypertrophy of the medial meniscus in children with early-onset disease. Growth plate irregularities and early physeal bar formation can also be determined.
CT with 3-D reconstructions is useful for preoperative planning in children with early-onset Blount disease presenting with recurrent deformities
Treatment of Blount Disease
Options for treatment of Blount disease include orthoses and surgery. If infantile Blount disease is diagnosed before age 4 years, non-operative treatment in form of orthoses has a role in Langenskiöld stage I or II diseases, especially with unilateral involvement.
In late-onset patients and early-onset patients in whom brace management fails, operative intervention is indicated.
Surgical options available are corrective osteotomy, lateral hemiepiphyseodesis, and guided growth around the knee, gradual asymmetrical proximal tibial physeal distraction, resection of a physeal bar, and elevation of the medial tibial plateau.
Knee-ankle-foot orthoses with a medial upright and drop-lock hinges in children younger than thirty-six months of age with early-stage (Langenskiold stage I or II) Blount disease.
Bracing must continue for approximately 2 years for resolution of bony changes though if successful, improvement is visible within 1 year. Outcome improves if the condition is unilateral.
Obesity with a weight greater than the 90th percentile, varus thrust, an age older than three years at the initiation of the brace treatment, bilateral involvement, and Langenskiöld stage-III or higher disease puts the treatment into a higher risk of failure.
Operative Management
Surgery is contraindicated in children < 2 years because it is difficult at this age to differentiate between Blount disease and physiologic bowing. Surgical outcomes are better if surgery is performed before 4 years of age.
Hemiepiphyseodesis
Hemiepiphyseodesis involves fusion of the lateral aspect of the proximal part of the tibia and relies on the growth of the remaining healthy part of the physis for angular correction.
Guided Growth
This procedure aims to correct further growth at the growth plate. Small metal plates are secured to the bone across the healthy side of the growth plate to halt the growth on that side of the tibia, which enables the affected, abnormal side of the growth plate to catch up, and therefore correct the deformity.
Both hemiepiphyseodesis and guided-growth systems are safe options but do not address limb shortening. These options may be considered for adolescents who have <15° of varus deformity, have at least two years of skeletal growth remaining, and have no more than 1 cm of limb shortening
Proximal Tibial Metaphyseal Osteotomy
Osteotomy can aim for acute correction or gradual correction.
Acute correction of angular and rotational deformity in Blount disease can be accomplished with a proximal tibial metaphyseal osteotomy. The type of osteotomy [closing wedge, opening wedge, dome, serrated, and inclined osteotomies] and type of fixation methods [cast immobilization, k-wires, interfragmentary screws, plates and screws, external fixators] depend on the patient's age, body habitus, the deformity, associated sagittal and axial plane deformities, and the surgeon's experience.
There is a potential for neurologic injury and compartment syndrome with acute correction.
Osteotomy with gradual correction employ the use of special external fixators like Taylor spatial frame and employ the principle of distraction osteogenesis. It is a safe and effective method with a lesser incidence of complications like neurovascular injury and compartment syndrome. Pin-site infection is a problem.
Asymmetrical Physeal Distraction
This method is used in adolescent patients and involves placing two 6-mm half-pins were placed into the proximal tibial epiphysis and two pins were placed into the diaphysis and gradual distraction without fibular osteotomy leading to angular correction of the deformity.
This method leads to premature closure of physis.
Physeal Bar Resection
This has been tried in children with advanced stages of early-onset Blount disease and involves resection of a physeal bar at the medial aspect of the proximal part of the tibia with interposition of fat or silicone and a simultaneous valgus osteotomy. Long-term follow up is not available
Elevation of the Medial Plateau
Elevation of the medial tibial plateau is recommended for the few children older than six years of age with Langenskiöld stage V or VI Blount disease and substantial posterior depression of the medial tibial plateau.
Infantile Blount disease has a good prognosis, and early treatment is associated with low recurrence.
Untreated infantile tibia vara is believed to be progressive though partial or complete regression is known in the early stages of the disease. However, later stages continue to progress and eventually lead to joint degeneration.
In the late-onset form of the disease, regression does not occur and the varus deformity may worsen over time.
Filed Under: Deformities, Non Traumatic, Pediatric Disorders
Erb's Palsy Causes, Presentation and Treatment
Erb's Palsy is also called brachial palsy or Erb Duchenne palsy and it occurs due to injury to the upper group of the arm's main nerves, specifically of the upper trunk [C5–C6 nerves]
Depending on the severity of the injury can either resolve on its own over a period or leave residual weakness.
Relevant Anatomy and Pathophysiology
Brachial plexus is formed of nerves roots from C5-T1 vertebra.
As these roots come out, C5 and C6 join to form the upper trunk, C7 travels alone as the middle trunk, and C8-T1 join as the lower trunk.
Erb's Palsy
Further, each trunk divides into anterior and posterior divisions and various divisions rejoin to form cords, which then subdivide further into branches that supply the muscles of the arm.
[Detailed anatomy of brachial plexus]
Erb's palsy affects nerves arising from C5 and C6. [Klumpke palsy affects C8 and T1]
Depending on the severity of the injury, the nerve injury can be neuropraxia, axonotmesis and neurotmesis
Neuropraxia denotes temporary loss of motor and sensory function due to blockage of nerve conduction. These lesions generally are reversible within 6-8 weeks and do not leave sequelae.
Axonotmesis means disruption of the myelin sheath and the axon, leading to degeneration of the axon distal to the injury. The connective tissue across the lesion remains intact. These injuries improve gradually over 4-6 months.
Neurotmesis means destruction of axon, myelin and supporting structures across a nerve. As the proximal end of the nerve attempts to regenerate without this supportive connective tissue, a neuroma may form. The improvement is variable.
An incidence of 0.8 -1.2 cases per 1000 birth has been reported. No sex predilection has been reported.
Causes of Erb's Palsy
Conventionally, birth injuries during the delivery process had been held responsible for Erb's palsy and other brachial plexus injuries presenting immediately after birth but recent observations and studies have suggested it to be also either due to stretching in utero or during the descent of the fetus. The occurrence of shoulder dystocia has been related with 18.3-32% increase in risk.
As brachial plexus injuries are found more in babies with greater birth weight, and these babies are more associated with shoulder dystocia, it has been recommended when the estimated birth weight exceeded 4.5 kg option of a cesarean section should be discussed with mothers.
Large birth weight
Breech presentation
Maternal diabetes
Multiparity
Traction on the head or assisted delivery
Intrauterine torticollis
Less common risk factors are a neoplasm, intrauterine compression, humeral osteomyelitis, hemangioma and exostosis of the first rib.
Presentation of Erb's Palsy
Usually, the baby is born after a difficult delivery and after delivery, the affected arm hangs loosely at the child's side. Respiratory depression may indicate an associated phrenic nerve palsy.
The infant with an Erb's palsy keeps the arm adducted, internally rotated, with the elbow extended, the forearm pronated, the wrist flexed, and the hand in a fist [Waiter tip deformity]. Sometimes, the limb is flaccid.
There might be associated injuries to clavicle, humerus. Cephalohematoma and facial nerve palsy may be found in some cases.
Baby may lack a Moro reflex on the affected side.
In patients where the injury, the affected arm may develop more slowly than the healthy arm and may be much smaller and may have impaired muscular, nervous and circulatory development leading to reduced healing ability of the skin, incomplete sensory perception.
Lab studies generally are not necessary.
High-resolution MRI is the best imaging study for this palsy. It shows the extent of trauma, including pseudomeningocele, and the presence of roots in the neural foramen.
Plain radiographs can be helpful in diagnosing hemidiaphragm paralysis from phrenic nerve involvement and fractures of the clavicle or humerus. X-rays also help to rule out posterior shoulder dislocation.
Electrodiagnostic studies like electromyography at 2-3 weeks can indicate on the severity and timing of the injury.
Some babies recover on their own. However, some may require intervention. Physical therapy forms an important part of both the conservative and operative treatment.
This begins as early as possible. Initially, the arm is fixed across the child's chest by pinning of clothing to provide more comfort. Gentle range of motion exercises. While dressing, the arm should be gently dealt to avoid further traction on the limb.
Wrist extension splint may help to reduce the risk of contractures.
Physical activity that involves both the limbs should be encouraged. Some examples of these activities are swimming, basketball playing etc.
Apart from this, activities for strengthening and promotion of sensory awareness should be done, and provision of instructions for home activities. Overall goals should focus on minimizing bony deformities and joint contractures associated with brachial plexus palsy, while optimizing functional outcomes.
Hand and wrist splints, elbow extension splints, dynamic elbow flexion, and supinator splints help to reduce contractures and prevent further deformity. In older children with persistent disability, self-stretching and strengthening exercises should be done.
Without physical therapy, there is a risk of progressive contractures, posterior shoulder dislocation, and agnosia of the affected limb.
The three most common surgical treatments for Erb's Palsy are
Nerve transplants
Subscapularis releases
Latissimus Dorsi tendon transfers.
Subscapularis Release
Subscapularis release aims at lengthening of subscapularis muscle by a Z shaped cut. It can be carried out at almost any age.
Latissimus Dorsi Tendon Transfers
Latissimus Dorsi is cut half horizontally, pulled in part and attached the outside of the biceps. This procedure provides external rotation.
Surgeries commonly performed are neurolysis and excision of the neuroma and nerve graft reconstruction.
Nerve Surgeries
Surgical intervention is said to be most effective when performed in patients as young as 2 months.
Neurolysis is the removal of scar tissue around the nerve. This is done if there is enough conduction across the neuroma. Otherwise, excision of the neuroma and nerve grafting is done.
Nerve transfer (neurotization) is required in cases where there is not a sufficient donor nerve, as in cases of avulsion.
Tubulization uses a conduit to help guide the 2 ends of a nerve together.
Other Surgeries
Late surgery for BPP most often involves tendon transfers and/or osteotomies.
The treatment aims at improving the flexibility and active movement of the shoulder.
Tendon transfers often are delayed until age 2-4 years to allow for motor recovery. The most common transfers include triceps to biceps and pectoralis major or latissimus dorsi to biceps.
A humeral external rotation osteotomy can be considered in older children for functional improvement.
Neuromuscular electrical stimulation and botulinum toxin A therapy have been suggested bu the role is not clear.
Filed Under: Deformities, Pediatric Disorders
Hemophilic Arthropathy
Hemophilic arthropathy is term given to changes in joints caused by recurrent bleeding into joint due to a bleeding disorder called hemophilia. Hemophilia is a genetic disorder characterized by abnormality of the coagulation mechanism due to functional deficiency of a specific blood factor, namely VIII or IX.
The name hemophilia was coined by Hopff in 1828. Wright demonstrated that the disorder involves prolonged clotting time.
The estimated incidence is between 0.8-1 per 10,000 male births. Hemophilia may be classified as follows:
Hemophilia A
This results from a congenital deficiency of factor VIII or antihemophilic factor or antihemophilic globulin. It constitutes 80 percent of cases and is X linked. Hemophilia A manifests in the male and is transmitted by asymptomatic female carriers.
Hemophilia B
Hemophilia B occurs due to a deficiency of factor IX ( also called plasma thromboplastin component or Christmas factor). It occurs in 15% of the cases and manifestations are similar to Hemophilia A. The hereditary transmission is also by an X-linked recessive gene.
Von Willebrand's Disease
In this bleeding disorder, both factor VIII deficiency and platelet functional abnormality are present. It is inherited as an autosomal dominant trait, occurring in both males and females. The bleeding disorder is relatively mild.
Symptoms and Signs of Hemophilia
Repeated episodes of bleeding which are not easily controllable are the hallmarks of hemophilia. The severity of the disease varies from patient to patient and depends on levels of the deficient factor.
The factor is 25 to 50 of normal and excessive bleeding occurs only after major trauma or during surgery.
When the plasma level of the factor is 5 to 25 percent of normal, the hemophilia is moderate. Severe uncontrolled bleeding occurs after a minor injury or during an operative procedure.
Moderately Severe
When plasma level of the factor it is 1 to 5 percent of normal, the hemophilia is moderately severe. Severe bleeding occurs after a minor injury or unrecognized mild trauma.
Very Severe
When the plasma levels of factor <1%, hemophilia is considered very severe. There are repeated spontaneous bleedings into joints and bleeding into deep soft tissues occur.
In severe cases, the abnormal bleeding may manifest itself in the neonatal period or early infancy which is noticed by the parents when the child begins to crawl or walks.
Joints are the most frequent sites of repeated bleeding followed by muscles and soft tissues.
Image Credit: Case courtesy of Dr Jayanth Keshavamurthy, Radiopaedia.org. From the case rID: 38990
Pathophysiology of Hemophilic Arthropathy
The weight-bearing joints are most commonly affected.
Frequency of involvement knee>elbow>shoulder> ankle>wrist>hip.
The vertebral column is rarely involved.
Following injury, the synovial vessels rupture, and blood accumulates in the joint. Bleeding continues until the intraarticular hydrostatic pressure exceeds that of the arterial and capillary pressure in the synovium. This causes ischemia of the synovium and subchondral bone.
With repeated hemorrhage, hyperplasia and fibrosis of the synovium ensue.
Pannus [thickened synovial tissue] formation erodes the hyaline cartilage peripherally which leads to loss of joint motion and contractural deformity occurs.
Subchondral bone cysts are formed due to local ischemia.
An attempt to repair may lead to asymmetrical growth, resulting in valgus or varus deformity.
Early closure of physis may lead to limb shortening.
Osteoporosis and muscle atrophy are common.
The final phase of hemophilic arthropathy is fibrous ankylosis.
Clinical Presentation of Hemophilic Arthropathy
These depend on the severity of hemorrhage and whether the bleeding in the joint is acute, subacute, or chronic.
An acute bleeding in the joint will lead to pain and swelling of the joint resulting in distention of the joint capsule. This causes pain which decreases only when the bleeding stops.
On examination, the joint involved would assume a position where it is in minimum discomfort which would also be the position of minimum pressure.
For example, the hip is kept in 30 to 65 degrees of flexion, 15 degrees of abduction, and 15 degrees of lateral rotation. The knee joint is held in flexion.
The intense pain of acute hemarthrosis subsides rapidly after the administration of factor VIII or IX.
Subacute hemarthrosis develops after several episodes of bleeding into the joint. Pain is minimal. The synovium is thickened and boggy. Restriction of joint motion is moderate.
Chronic hemarthrosis develops after six months of involvement. Progressive destruction of the joint leads to a fibrotic, stiff, totally destroyed joint.
Radiograms will disclose soft-tissue swelling due to distention of the joint capsule. With repeated hemorrhage and resultant chronic synovitis, there may be
Enlargement of the epiphysis
Subchondral cysts,
Narrowing of the articular cartilage space
Formation of peripheral osteophytes.
Finding in Knee
widened intercondylar notch
squared inferior margin of the patella
bulbous femoral condyles
flattened condylar surfaces
Finding in Elbow
enlarged radial head
widened trochlear notch
Talar tilt due to relative undergrowth of the lateral side of the tibial epiphysis leading to a pronated foot.
Classification of Hemophilic arthropathy
The classification is based on radiographs.
Soft-tissue swelling, but no skeletal abnormalities.
Overgrowth and osteoporosis of the epiphysis, joint integrity is maintained. There are no bone cysts and no narrowing of the articular cartilage space.
The radiologic Stage II parallels the clinical stage of subacute hemophilic arthropathy.
Minimal to moderate joint space narrowing with subchondral cysts. Widening of the intercondylar notch of the knee and the trochlear notch of the ulna. In the knee, there may be squaring of the patella.
Articular cartilage is still preserved and hemophilic arthropathy is still reversible.
Destruction of articular cartilage with severe narrowing of the joint space. The other osseous changes found in stage III are more pronounced.
Total loss of joint space with fibrous ankylosis of the joint. There is marked incongruity of the articular structures with severe irregular hypertrophy of the epiphysis.
Treatment of Hemophilic Arthropathy
Treatment of Acute Episodes of Bleeding
Factor Replacement
The main concern in hemophilic arthropathy is the spontaneous bleeding. The aim of treatment is to prevent the bleeding.
This is done by replacement of deficient factor with a concentrate of the clotting factors obtained from fresh frozen plasma.
For Factor VIII deficiency (hemophilia A and von Willebrand's disease) the concentrate used contains factor VIII and fibrinogen. Commercially prepared cryoprecipitates are available.
For factor IX deficiency (hemophilia B) the concentrate used contains a high level of factor IX and low levels of factors, II, VII, and X. It is manufactured as the prothrombin complex from human plasma.
In case of the management of bleeding into joints, muscles, and soft tissue, the dose of factor VIII or IX is calculated to raise the plasma level to 30 percent of normal.
In severe hemarthrosis, it may be desirable to raise the plasma level to 40 percent of normal.
One of the problems with factor replacement therapy is developing inhibitors of factor VIII and IX as a result of the immunologic response.
Initially, a low titer of inhibitors may be circumvented by high dosage of factor infusion. In severe cases, the administration of prednisone and cyclophosphamide or of plasmapheresis may be required.
It takes about 20 minutes for the plasma levels of the factors to rise.
The biologic half-life of factor VIII is 6 to 12 hours, whereas that of factor IX is 8 to 18 hours.
Radiosynoviorthesis
radioisotopes can be injected therapeutically into a joint to decrease bleeding and synovitis
The affected joint is temporarily immobilized in a position of rest and minimum intraarticular pressure.
A compression helps to create tamponade and reduce further bleeding but distal circulation should be carefully watched.
Under no circumstances should a circular plaster cast be used. The swelling will obstruct the distal circulation and cause gangrene.
The limb should be elevated and Cold compresses are applied over the affected joint. The clotting defect is corrected by administration of antihemophilic factor.
It is best to avoid analgesics or sedative. NSAIDs are contraindicated due to an inhibitory effect on platelets. With opioid drugs as addiction can be a problem with repetitive use. If the patient is under the effect of analgesia he will be unable to get a proper warning of continued bleeding.
The decrease of the severity of pain is the first indication of cessation of hemorrhage. Monitoring the circumference of the joint at intervals also tells the progress.
However, in case of need opioid drugs may be given but they should be used conservatively. If the pain is intolerable and does not respond to factor replacement and splinting, pain medications that can be given are propoxyphene, acetaminophen, codeine.
Joint Aspiration
The joint should be aspirated and decompressed if there is severe hemarthrosis with marked distention of the joint capsule.
Aspiration of the joint should be performed under strict aseptic conditions in the operating room and under local anesthesia. Following that Factor VIII or IX is administered intravenously. After the aspiration, the compression dressing and posterior splint are reapplied. Administration of the factor is continued for three to seven days following cessation of bleeding.
After cessation of bleeding, physical therapy to mobilize the joint is initiated. Isometric muscle exercises, gentle active assisted exercises are carried out intermittently. The range of motion of the affected joint is progressively increased. Full weight-bearing is not permitted as necessitated by a limitation of joint motion and muscle weakness. Transition to activity is gradual.
The treatment depends on whether the arthropathy is acute or chronic.
Subacute hemophilic arthropathy occurs when repeated episodes of bleeding into a joint occur in a relatively short time. This results in synovial hypertrophy and persistent effusion. Subacute hemophilic arthropathy is best managed by immobilization of the joint, factor replacement and followed by physical therapy.
Most of subacute hemarthroses resolve over a period of three to four weeks.
If the subacute hemarthrosis fails to respond to three weeks of partial immobilization, physical therapy, and factor replacement, prednisone or a similar steroid is given for one week in the appropriate dosage.
Prolonged immobilization of the affected joint should be avoided, as this results in marked muscle atrophy and restriction of joint motion.
Support of the lower limb in orthotic devices is indicated when mechanical insufficiency of the lower limb predisposes the child to fall and sustain repeated injury.
Chronic condition results after repeated acute hemophilic arthropathy. Repeated acute episodes result in intra-articular fibrosis, cartilage destruction, and joint stiffness. This condition is preventable in most cases by effective and immediate treatment of acute hemarthrosis.
In the management of chronic hemophilic arthropathy, physical therapy, traction, orthoses, traction, and surgery play an important role. Treatment needs to be individualized. The objective is to correct joint deformity and to restore function.
Modalities Used in Treatment of Hemophilic Arthropathy
In flexion deformities of the knee and hip, a period of continuous traction is effective in relieving muscle spasm and increasing range of motion. Initially, traction forces are in the line of deformity and are gradually altered to achieve correction.
Prophylactic protection with antihemophilic factor is usually not required while the patient is in traction. Once a neutral or a nearly neutral position is obtained, well-padded plastic splints are used to maintain the part in the corrected position.
Active exercises are begun to increase muscle power and range of motion of the joints.
Plaster Cast
As highlighted previously, if a functional range of motion is not achieved after two or three weeks of traction, a wedging cast is applied. The antihemophilic factor is administered when the cast is wedged.
When full joint motion is achieved the knee is immobilized for a period of seven to ten days and maintained in a plastic splint.
Physical therapy in the form of active exercises is begun and increased gradually.
If bleeding occurs during physiotherapy, it is controlled by intravenous administration of antihemophilic factor.
Forceful manipulation of a joint under general anesthesia is not recommended.
If deformities caused by hemarthrosis cannot be corrected by conservative closed methods, surgical correction is indicated. For example, if equinus deformity is very severe and rigid, tendo Achillis lengthening is indicated.
Open surgery has become relatively safe, provided the clotting mechanism is restored to near normal by the administration of antihemophilic factor. This should be continued for three weeks. Sutures should be removed on the fourteenth to sixteenth day postoperatively.
Wounds heal normally in hemophilic patients.
During surgery and the first postoperative day, the factor level should be raised to 100 percent by infusion of factor concentrate. During the first postoperative week, the factor level is maintained at 50 percent, and subsequently for the first postoperative month at 30 to 40 percent by daily infusions of factor concentrate.
Synovectomy
Synovectomy is done to prevent progression of hemophilic arthropathy. It helps by
Decreases the vulnerability to the trauma of the highly vascular synovial tissue i
Hemophilic synovial tissue has a high level of fibrinolytic activity that tends to prolong the bleeding episodes.
Hypertrophic synovial tissue in hemophilia contains increased levels of acid phosphatase and cathepsin D.
Hemosiderin deposition in the synovium interferes with the production of collagenases, which may cause the death of chondrocytes.
Synovectomy is indicated in
History of severe recurrent hemarthrosis -two or three major bleeding episodes per month
Patients who fail to respond to aggressive medical management for a period of at least six months.
Failure of response to orthopedic nonsurgical treatment
Radiographic Stage II or Stage III hemophilic arthropathy
In stages IV and V, synovectomy is not effective and contraindicated.
Total joint replacement in bilateral knees is indicated with Stage IV or Stage V arthropathy when persistent knee pain is present.
Total hip replacement is indicated in Stage IV or Stage V hemophilic arthropathy when pain is persistent with a severe disability not relieved by conservative measures. Arthroplasty of the elbow has been reported.
Arthrodesis of the ankle, subtalar and midtarsal joints in the foot, shoulder, or knee may be indicated when these joints are destroyed.
Filed Under: Arthritis, Deformities
Symphalangism – Causes, Classification and Treatment
Symphalangism is congenital stiffness of the digits which occur due to the fusion of the joints of the fingers or toes leading to functional impairment and unsightliness of the affected finger. The condition was first described by Harvey Cushing. The proximal interphalangeal joint is most commonly involved. It can be hereditary or nonhereditary and the association has been found with syndromes like Apert and Poland.
Symphalangism occurs due to the failure of separation of the phalanges and results in the fusion of one phalanx to another within the same digit. It may occur as a simply isolated malformation or it may be associated with other deformities of the hands or feet, and it may also occur in numerous congenital syndromes such as Apert's, Poland and Mobius syndrome.
When hereditary, symphalangism is usually inherited as a dominant trait.
It is most frequently found in Caucasians, occasionally in Orientals, and hardly ever in blacks.
Grades of Symphalansim
An Attempt has been made to classify symphalangism based on radiographic appearance.
This classification is as follows
Grade I or Fibrous Symphalangism
is present when there is mild joint space narrowing in the affected joint
Grade II or Cartilaginous Symphalangism
Only a slit of joint space is observed.
Grade III or Bony Symphalangism
There is bony ankylosis visible
Grades of Symphalangism, A -Normal Joint, B- Fibrous Symphalangism, C-Cartilaginous Symphalangism, D – Bony Symphalangism, Image Credit: Baek etal
In a very young child, over the involved joint, volar skin crease may be absent or faint. Joint capsule and ligaments may be tight, allowing minimum motion of the affected joint. As the joint grows, it may fuse.
Thus, the same joint can be classified as fibrous, cartilaginous, or bony symphalangism according to the child's age at diagnosis.
Presentation of Symphalangism
The congenital stiffness of the digits is the main presentation.
The disorder is characterized by a lack of motion of the affected joint in the finger. The skin overlying the fused articulation is smooth, and the transverse skin creases are absent.
This condition can be easily detected at birth.
Usually, more than one finger is affected. When the proximal interphalangeal joint is affected, the digit is usually fixed in extension. At the level of the fused joint, the soft tissues are narrowed.
The patient cannot make a fist and has difficulty picking up small objects.
The x-ray may reveal any of the above-mentioned grades of symphalangism, depending on the age of the child. One cannot detect it radiographically at birth because of lack of ossification of the phalanges around the affected joint. With growth and maturation, when the bones ossify, there is a decrease in the joint width with eventual fusion.
Treatment of Symphalangism
Treatment is individualized.
The digits that are fixed in extension will be functionally improved by flexion osteotomy.
In symbrachydactyly, when there is an associated shortening of the fingers, one may gain relative length by recessing the interdigital webs into the spaces between the metacarpal heads.
Also, one may lengthen digits surgically.
Recent reports have suggested that the early release of the fusion when it is in fibrous stage may restore some motion. The child should be operated for this as early as possible.
The management of symphalangism with associated anomalies is complex. One should individualize the care; often it is difficult to improve function.
Filed Under: Pediatric Disorders, Deformities
Polydactyly Presentation and Treatment
Polydactyly means extra digits – in the hand or foot. Broadly speaking, there are three types of polydactyly
Postaxial or Ulnar
Preaxial or Radial
It is the most common type of polydactyly where the extra digit is on the ulnar side of the hand [side of the little finger].
Most commonly, the extra finger is rudimentary, consisting of an end phalanx with a nail, and connected to the hand with a small skin pedicle.
In case of a fully developed extra finger, the duplication usually presents itself at the level of the metacarpophalangeal joint. Triplication of the little finger is very rare.
In about 14% of the cases, this type of polydactyly is hereditary.
It is further of three types.
Type I includes nubbins or floating little fingers
Type II includes duplications at the metacarpophalangeal joint.
Type III includes duplications of the entire ray
Preaxial polydactyly or extra thumbs are the common, occurring incidence of the deformity is 0.08 per 1000.
Duplication of Thumb- An example of Polydactyly
polydactyly Volar View
Polydactyly Dorsal-view
It ranges from a small fleshly webbing on the radial border of the hand to triplication. There are seven types of duplicate thumbs.
Type I – The distal phalanx is bifid
Type II– The distal phalanx is duplicated
Type III – The proximal phalanx is bifid but the distal phalanx is duplicated
Type IV – Both the proximal and distal phalanges of the thumb are duplicated
Type V – The metacarpal of the thumb is bifid, the proximal and distal phalanges are duplicated
Type VI – The thumb metacarpal and both proximal and distal phalanges are duplicated (4 percent) and
Type VII – The thumb is triphalangeal
Preaxial polydactyly may be associated with syndactyly, it is inherited as an autosomal dominant trait and is termed as polysyndactyly.
In thumb duplication, circulation may be anomalous, being supplied by one artery instead of two. Often one of the thumbs is dominant while the other is underdeveloped; sometimes, however, both thumbs are of equal size, posing a problem as to which one to ablate.
Thumb polydactyly is usually sporadic, though if associated with triphalangeal thumb it may be familial.
Preaxial polydactyly may be associated with vertebral anomalies, the absence of the tibia, cleft palate, and imperforate anus. It may also be seen in a number of syndromes.
They may be of special clinical importance are Down's syndrome, Fanconi pancytopenia, and acrocephalosyndactyly.
Duplication of the index, long, and ring fingers is referred to as axial or central polydactyly. Often the extra digit of a long or ring finger is concealed in a web between adjoining normal digits.
The tendons, nerves, and vessels of the supernumerary digits are usually abnormal, as are the epiphyses of the extra digit.
The epiphysis of the extra digit usually does not lie in the normal line of growth. As a result, its phalanges diverge from the longitudinal axis into ulnar or radial deviation and distort adjacent digits.
Duplication of the index finger is very rare, representing about 3.5 percent of all cases of polydactyly.
This anomaly should not be confused with the triphalangeal thumb. The extra index finger may consist of a pedunculated soft-tissue mass or it may have normal bony and soft-tissue components. It may be associated with congenital radioulnar synostosis, and occasionally the duplicated index finger may be fused to the long finger.
Treatment of Polydactyly
If the duplicated small finger is hypoplastic, rudimentary, and attached to the hand by a narrow pedicle it can be removed in the newborn.
The fully developed and complete extra little finger needs to be excised and can be done at a later date.
Operative treatment for preaxial type is more complicated.
The important considerations are
To maintain size and stability
To provide adequate motor control and strength
To establish anatomic alignment.
The type of treatment varies according to the type of thumb duplication.
If one of the two thumbs is significantly smaller or if only one deviates from the anatomic axis, the smaller accessory thumb is ablated.
However, at skeletal maturity, the thumb would be smaller than the opposite thumb.
Congenital Anomalies of Shoulder
Congenital Dislocation Of Shoulder
It is one of the congenital anomalies of the shoulder where the dislocation of shoulder present at birth. It is of three types
True congenital dislocation, developing in utero [Extremely rare]
Dislocation caused directly by trauma at birth
Acquired dislocation developing secondary to a brachial plexus injury. It is the most common type
Etiology of Congenital Dislocation of Shoulder
In utero maldevelopment is the major cause for true congenital dislocations of the shoulder. This usually occurs due to bony abnormalities of the shoulder girdle.
The bony abnormality can be hypoplasia of the scapula or glenoid dysplasia.
Xrays can detect and differentiate congenital dislocation of the shoulder from upper humeral fractures.
CT and MRI are much more sensitive in the diagnosis than radiographs and should be used when in doubt.
When functional impairment is minimal, no treatment is indicated because there is a possibility of further decreasing functional use of the limb.
Operative procedures employed depend on the individual case.
Where indicated, early reduction and containment of the humeral head in the glenoid socket might help achieve a satisfactory long-term outcome. Open reduction may be required for release of contractures.
In severe aplastic malformations, surgical measures are often futile because the function cannot be improved.
Congenital Glenoid Hypoplasia
This malformation is due to failure of formation of the lower and upper glenoid epiphysis. It is characterized in the radiogram by flattening, shallowness, and an underdeveloped appearance of the glenoid cavity.
The lower aspect of the clavicle may be hypertrophied into a bony prominence, and there may be spina bifida in the cervical region.
Often, the abnormality is bilateral and is encountered as an isolated malformation. It may be hereditary. Samilson reported congenital glenoid hypoplasia in three successive generations of the same family.
Occasionally, it is seen in association with other congenital malformations such as Apert's syndrome, Hurler's syndrome, aglossia-adactylia, oculodento-osseous dysplasia, Holt-Oram syndrome, and Cornelia De Lange's syndrome.
Clinically, in the young child, the anomaly is usually asymptomatic and may be found incidentally in the radiogram. In the older patients, however, the glenohumeral joint may be unstable and may become dislocated posteriorly.
The range of abduction of the shoulder will be restricted, and occasionally it may cause neurovascular embarrassment. In the differential diagnosis, one should consider glenoid hypoplasia secondary to obstetrical brachial plexus palsy or multiple epiphyseal dysplasias.
Management should be individualized. Often no treatment is indicated.
In symptomatic posterior dislocation of the shoulder, glenoidplasty with a bone graft may help.
Aplasia of Scapula
Congenital absence of the scapula is extremely rare. It is usually associated with ipsilateral Amelia. Treatment consists of fitting with an upper limb prosthesis.
Torsional Deformity of Glenoid Cavity
This deformity will cause posterior or anterior dislocation of the shoulder and can be demonstrated on an axillary radiogram or a computed tomographic torsion study of the glenoid cavity.
Treatment consists of osteotomy of the neck of the scapula and insertion of a wedge bone graft to correct the abnormal glenoid torsion.
Congenital Varus Deformity of Proximal Humerus
This malformation may be developmental or secondary to neurofibromatosis or rachitic syndromes.
Torsional Deformity of Humeral Neck
Excessive retroversion will cause posterior dislocation of the glenohumeral joint, and excessive anteversion will cause anterior dislocation. Computed axial tomography will show the degree of humeral torsion. When torsion deformity is severe and is causing shoulder joint instability, it is treated by derotation osteotomy.
Filed Under: Deformities
Gonococcal Arthritis – Symptoms, Diagnosis an Treatmetn
Gonococcal arthritis is caused by Gonococcal bacteria, that cause sexually transmitted disease, Gonorrhoea. Gonococcal arthritis is the most common type of septic arthritis constituting 70 percent of episodes of infectious arthritis in persons under 40 years of age. Pathophysiology and Etiology The infection typically results from bacteremia arising from gonococcal infection which may be asymptomatic […]
Tibia Anatomy and Attachments
Leg is the part of the lower limb between knee and ankle. The osseous framework of the leg is composed of two bones –tibia and fibula. The tibia is a medial and larger of the two bones. The bone is similar to the radius bone of the upper limb. Structure of Tibia Like all bones, […]
Ulnar Gutter Splint Application Procedure
An ulnar gutter splint extends from the proximal forearm to distal interphalangeal joints of fingers on the ulnar aspect of fingers wrist and forearm and is applied for various injuries of the ulnar aspect of the wrist and hand. It is also called Boxer splint. The splint is applied on the ulnar aspect and conforms to […]
Fibromyalgia – Symptoms, Diagnosis and Treatment
Fibromyalgia or fibromyalgia syndrome is a disorder that is characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, memory problems, allodynia, and mood alterations. Difficulty in swallowing. bowel and bladder abnormalities, paresthesia and cognitive dysfunction have also been reported to occur in some patients Symptoms may begin after a physical trauma, surgery, infection or significant psychological […]
Muscles of Hip
Muscles of the hip joint are those muscles that cause movement in the hip. The muscles of the hip consist of four main groups. Gluteal Group The gluteal muscles cover the lateral surface of the ilium and include Gluteus maximus Gluteus medius Gluteus minimus Tensor fasciae latae Adductor group This group includes Adductor brevis Adductor […]


Searching for "Hvac Mep Engineers" job or career in United Arab Emirates (UAE)? Welcome to CareerDP, your all in one easy to use job site that can assist you to any job search. We wish you a good luck and have a prosperous career.
Hiring Organization: Alyanbou Electromechanical Works(L.L.C).
Data as of 2019-04-01 (Latest) with id 44654.
If you are switching jobs: Once you change your job, choosing the best corporation and the surroundings in which you can work will usually be only half of the job you should perform for the change of your career. It's also very important to discover a solution to elegantly leave your prior job. It's advocated that you maintain genuine contacts with former co-workers and bosses.


The joining of two hearts, two culture and two dreams, This can be the tag which we can add to the sacred ceremony, Marriage. The attestation of this proof ( Marriage certificate) is mandatory for innumerable purposes. This includes the approval and issue of family vis and other overseas formalities. The issue of family visa, dependent vis etc is made strictly on the attestation of the certificate. The sacred proof of a sacred life should be handled and legalized in way which can understand the value of your emotions. We, the Global leaders in attestations can asst you for a bright family and future abroad. Your Smile and satisfaction is our goal.
Certificate attestation is the most fundamental in which authorized personnel affirms the authenticity of a document by verifying its originality with his signature.
To null and void the discrepancies that might mount after pointing a finger on the authenticity of a document, attestation of the same is very essential so that it can be furnished enough to be treated as a legal paper.There is always a confusion regarding the words 'authentication' and 'Attestation' The Authentication is described as simply the verification process where as the Attestation can be summarized as 'Embassy Attestation'.
The authenticity of the documents which is to be presented for attestation or any other procedures has to be found out.This can be usually done by thoroughly verifying the presented documents whether it is legally viable or not.Mumbai Authentication refers to the authentication of documents presented for various attestation purposes in Mumbai office .only after this authentication process is completed ,one can surely say that all the documents presented for attestation is true and the further processing can be done.Thus the Authentication forms an important part of Certificate attestation.


Everyday life is full of magic. All you have to do to see it is look closely enough.
Heather is caring for a grave, the final resting place for little Anna from long ago. Heather ponders what Anna's life was like. Meanwhile, Raoul and Rod are trying to figure out where they can get the money they need for this one really important thing. Thom comes across a strange bottlecollector. And Jack meets a mysterious water-cat, who talks big about building a spaceboat. Who on earth danced on the kitchen table last night with muddy shoes? And what does it feel like to be a stone?
Sari Peltoniemi's everyday tales are composed of the joys and sorrows of the young, their finest moments and their gray days, too. They are about you, me, and Tuva from next door. Liisa Kallio's sensitive illustrations are a fine complement to the tales' wonderful ambiance.


Shimla: The Himachal Pradesh Government is ensuring one time relief to the small and marginal farmers of the State, by adopting lenient approach to the marginal farmers, who had encroached upon the government, by conferring proprietary rights to them.
High Powered Committee of the State Government, in its meeting today, revealed the scheme for giving proprietary rights to a maximum of five bighas of land in rural areas had been prepared. However, scheme will also ensure that own land of the person and the land conferred would not exceed a total of 10 bighas, provided that the remaining land in possession was vacated.
Revenue and Law Minister Kaul Singh Thakur, in a committee meeting constituted to assess and review the encroachment cases in the State, said the proprietary rights were proposed to be conferred at nominal rates. For conferment of Proprietary Rights, the person would have to apply in writing to the concerned SDO (Civil) or Assistant Settlement Officers where settlement operations were in process.
Kaul Singh said that land being used for common village purposes such as roads, forest, fair grounds and other common purposes would not be conferred. He said that in those cases where the possessor stands already evicted within two years of the cut-off date would also be considered for conferment subject to the condition that the cases had been recorded before August, 2015.
The Minister said the State government would also consider the exchange of private land in lieu of encroached government land by the farmers. He said that the Scheme would be placed before the Cabinet for approval.
The Revenue Minister said that in cases where clearance under the Forest Conservation Act, 1980 and the Scheduled Tribes and Other Traditional Forest Dwellers (Recognition of Forest Rights) Act, 2006 was mandatory would be taken with the Government of India for exemption on humanitarian grounds and for determination of the Rights of possessors/dwellers.
Thakur said the State Government was committed towards welfare of the small and marginal farmers. He said that the State Government has drafted a scheme to protect the livelihood rights of the small and marginal farmers. However, the government was also committed to take strict action against the big encroachers as per the law, he added.
Deputy Speaker, Vidhan Sabha, Jagat Singh Negi, Chief Parliamentary Secretaries Nand Lal and Rohit Thakur, MLA Mohan Lal Brakta, Additional Chief Secretary, Revenue, Tarun Shridhar, Principal Secretary, Forests Tarun Kapoor, Principal Secretary, Law Dr. Baldev Singh Thakur, Principal Chief Conservator of Forests S.S. Negi and other senior officers were also present among others.


text:
Bronisław Gąsiorowski (ur. 14 marca 1898, zm. 31 sierpnia 1920 w Zamościu) – podchorąży Wojska Polskiego, kawaler Orderu Virtuti Militari.

Życiorys
Urodził się 14 marca 1898 w rodzinie Józefa i Władysławy z Holców (zm. 1944). Studiował na Politechnice Warszawskiej. Był barwiarzem korporacji akademickiej "Sarmatia". W 1920 w czasie wojny z bolszewikami walczył w załodze pociągu pancernego "Zagończyk". Zmarł 31 sierpnia 1920 w Zamościu w następstwie odniesionych ran. 4 października 1920 został pochowany na Cmentarzu Powązkowskim w Warszawie.

Ordery i odznaczenia
 Krzyż Srebrny Orderu Wojskowego Virtuti Militari nr 5136

Przypisy

Bibliografia

Odznaczeni Krzyżem Srebrnym Orderu Virtuti Militari (II Rzeczpospolita)
Pochowani na cmentarzu Powązkowskim w Warszawie
Polscy korporanci
Polegli w wojnie polsko-bolszewickiej (strona polska)
Urodzeni w 1898
Załogi polskich pociągów pancernych w wojnie polsko-bolszewickiej
Zmarli w 1920

redpajama_set_name: RedPajamaWikipedia


text:
name: Karanbir Toor
affiliation: AdStage
city: "San Francisco, CA"
---

I graduated in 2013 with a degree in Physics and Computer Science. Joining CCS
was easily one of the best decisions I made in my life. The flexible curriculum
and individualized attention gave me an education custom made for my interests
and ambitions. The small classes gave me an ideal environment for learning.
Lastly, CCS gave me a great network to leverage and the best of friends.

Now I work for [AdStage][adstage], a startup in San Francisco, and enjoy [blogging][blog] about
Lisp.

[adstage]: https://www.adstage.io/
[blog]: http://www.currentoor.com/

redpajama_set_name: RedPajamaGithub


bedroom drapes and curtains. Here you are at our website. At this time were excited to declare that we have found an incredibly interesting niche to be pointed out, that is bedroom drapes and curtains. Some people attempting to find specifics of bedroom drapes and curtains and certainly one of them is you, is not it?
There are plenty of main reasons why you are researching for info about bedroom drapes and curtains, but certainly, you are looking for fresh suggestions for your considerations. We determined this on the internet sources and we believe this can be one of many awesome content for reference. And you know, initially when I first found it, we loved it, hopefully youre too. We believe, we may own different thoughts, but, what we do just like to support you in finding more references concerning bedroom drapes and curtains.
Master Bedroom Curtains Drapes Wayfair .
Drapes Around Bed Apartment Curtains Ceiling Drapes For Bedroom .
Navy And White Drapes Blue Bedroom Drapes Extraordinary Blue Bedroom .
Bedroom Curtains Drapes Re Program .
Curtains Drape Bedroom Purdah Living Room Blind Modern Fabric .
Grey Curtains For Bedroom Grey Bedroom Drapes Moeslah Co .
Bedroom Curtains And Drapes Bedroom Curtains And Drapes Drapes .
Curtains And Drapes Bedroom Curtains And Drapes Bedroom Curtains And .
Curtains For A Dining Room Blue Shower Curtains And Bath Accessories .
Modern Linen Blackout Curtains For Bedroom Brown Beige Window .
Bedroom Interior Curtains Ready Made Window Treatments Bedroom .
Graceful Living Room Suitable Light Gray Curtains Grey Curtains .
We Have Been Asked For This Type Of Full Volume Draping Curtains A .
Panel Goblet Fabric Pattern Soft Treatment Woven Wood Pillow Window .
Red Bedroom Curtain Bedroom Drapes Curtains Excellent Wonderful .
Natural Leaves Cotton Curtains For Living Room Bedroom Drapes .
Top Ideas For Bedroom Curtains And Window Treatments Drapes .
Bedroom Layout Bedrooms Pinterest Layouts Bedrooms And .
Draperies And Curtains Elegant Charter Home Ideas Draperies And .
Bedroom Curtains And Drapes Fancy In Living Room Double Window .
Interior Inspiring Home Interior Design With Red Maroon Drapery .
Bedroom Awesome Best 25 Curtain Ideas On Pinterest Curtains Window .
Bedroom Exquisite Tips For Choosing Curtains Style For Bedroom .
Curtain Gold Silk Curtains Faux Nugget Curtain Panels Antique .
Bedroom Drapes And Bedspread Bedroom Drapes And Bedspread Bedroom .
Bedroom Drapes And Curtains Asio Club .
Living Room Curtains And Drapes Ideas Laurinandlovellphotography Com .
Bedrooms Curtains Photos Zentanglewithjane Me .
White Drapes For Bedroom Bedroom Window Drapes Bedroom Drapes .
Master Bedroom Curtains Sitez Co .
Bedroom Curtains And Drapes Latest Curtain Designs For Bedroom .
Luxury Drapes Curtain Design Bedroom Green Gilded Crown Homes .
Master Bedroom Curtain Ideas Master Bedroom Draperies Master Bedroom .
Curtains For A Gray Room Mogams .
Cheap Curtains Drapes Online Curtains Drapes For 2018 .
Curtains Httpfeelthehome Comwp Contentuploads201204elegantp .
Drapes For Bedroom Windows Solid Twill Window Shade Thick Blackout .
Curtains Window Ideas For Bedroom And Drapes Small Windows Wall .
Pottery Barn Curtains And Drapes Bedroom Traditional With White .
White Blackout Curtain With Voile Overlay One Panel Custom .
Living Room Curtains And Drapes Bedroom Curtains And Drapes Curtains .
Elegant Curtains And Drapes Cigeh2017 Com .
Drapes Curtains Ideas Guest Bedroom Curtain Idea Already Have The .
Pin By AM Home Furnishing On Made To Measure Window Curtains UK .
Floral Curtains Bedroom Related Post Floral Bedroom Drapes Vilhena Me .
Bedroom Black Bed Drapes Canopy Curtain Panels Single Bed Canopy .
Designer Drapes Curtains Bedroom Drapes Curtains Description For .
Budget Friendly Ready Made Curtain Roundup Emily Henderson .


text:
Actual Experience (LON:ACT) Reaches New 52-Week Low at $125.00
IoT Chain 1-Day Trading Volume Tops $3.95 Million (ITC)
Investment Analysts' Updated EPS Estimates for July, 15th (ABB, BMWYY, CPCAY, CRVS, DDAIF, EBAY, FCAU, PUGOY, RACE, RNLSY)
ASX (ASX:ASX) Shares Pass Below Two Hundred Day Moving Average of $0.00
Alpha Real Trust (LON:ARTL) Stock Price Crosses Below Two Hundred Day Moving Average of $0.00
Murray now looks to earn more Slam titles
Posted by D Anicetti on Jul 8th, 2013
On Sunday, Andy Murray became the first man from Britain to win the men's Wimbledon singles title in 77 years. In the final, he took apart Novak Djokovic the No. 1 player in the world.
He won the U.S. Open last year as well and a gold medal at the London Olympics.
However, the Scot still is the No. 2 ranked player in the world in the latest ATP rankings.
The day after his victory Murray said he was much more interested in winning more Grand Slam tournaments that he was in reaching the No. 1 player plateau.
Murray has reached the final of the past four majors he has played in and has won two of them.
When asked on Monday about moving into the No. 1 spot Murray shrugged and said it is hard to believe he won two of the past four grand slam titles, the Olympic Gold Medal and still he is far from being the No. 1 player in the rankings.
He said it could be that he needed to be more consistent when it came to other events during the year.
He also is aware that he did not participate in the French Open this year due to an injured back and that did not help with his ranking.
However, he said he would rather not reach No. 1 and win additional titles in the Grand Slam events, than never win any more Grand Slam title but be No. 1.
One Grand Slam remains this year and the U.S. Open will be played in September in New York as it always is. Each of the previous three Grand Slams this season have been won by different men. Djokovic won the Australian, Rafael Nadal the French and now Murray has won Wimbledon.
Morningstar Reports Credit Card Data Leak
Make the most out of your favorite Baseball team's games this season
Cryptaur Achieves Market Cap of $4.44 Million
Nielsen Sees Large Volume Increase
MYnd Analytics Shares Up 7.4%
Electrify.Asia Reaches Market Cap of $1.13 Million
StableUSD Price Hits $1.00

redpajama_set_name: RedPajamaCommonCrawl


Apple's diminutive tablet is almost flawless in so many ways, so we've picked out all the cheapest iPad mini prices so you can find get the best deal on one. The series is getting on a bit now, but at least the latest iteration, the Apple iPad mini 4 is still in production. We're certainly ready for a new one by now though. At least father time's passing means prices continue to fall.
The design of the iPad mini is still the best in the tablet category, with no Android tablet really coming close in this class. The fast processor and premium design makes it a great looking tablet, too, and the Retina display on the newer models is simply stunning.
On top of that, you're getting an excellent OS and even gaming is sensational on this tablet. In short, it's the best 7-inch tablet out there. So here are all the best iPad sale prices so you can grab the best money-saving deal available.
Apple has finally revealed its first new iPad Mini since 2015's iPad Mini 4. It's not called the iPad Mini 5 though, Apple has instead opted to simply call it the iPad Mini, retailers are likely to call it the iPad Mini (2019) or all-new iPad Mini to help differentiate it from the oldest version though.
It shouldn't be hard to spot it though as the new iPad Mini (2019) will be the one with a starting price of $399 / £399 / AU$599 / AED 1599. Of course, the device itself has benefited from upgraded spec and a better screen over the older models, although you'd be forgiven for not seeing much difference in the look of the device.
The stunning new retina screen has a 2048 x 1536 resolution, which is seriously intense for a 7.9-inch screen. The battery will keep you going for a superb 10 hours of web surfing and media playback. You're getting most up-to-date OS and brand new A12 Bionic Chip that even outstrips the most recent regular 9.7-inch iPad. If the regular iPads are a bit too big for you, but you want something bigger than your phone for long reads, browsing the net or watching video content, the latest iPad Mini is going to take some beating as one of the best devices you can get.
One of the major changes with the iPad mini 4 over the older version is its design. It may look the same, but it's been slimmed down from 7.5mm to a wafer thin 6.1mm. It's also now more powerful, has a stunning screen and the battery is still a 10-hour beast. The A8 processor is a good step up from the A7 inside the mini 3 so if you're going to play 3D games or throw around some of the more hefty iPad apps from the App Store, this is certainly a solid option.
The price will start to drop more now that the new 2019 iPad Mini has landed. For a while though, you might find prices aren't a million miles apart, meaning you might want to spend a bit more on the newest version for the extra speed and higher resolution screen.


I collected a dozen eggs today. That's right, I filled an entire egg carton in one trip to the coop. We have been averaging 10 eggs a day for the past week, so this moment was extremely exciting.
As a special treat, I cut a bunch of borage from the kitchen garden and took it out to the chickens.
They LOVE borage…almost as much as watermelon.
We have three slackers. I'm not sure who they are yet, but I suspect three of the older hens have run out of eggs.


text:
module Fog
  module Compute
    class Google
      class Mock
        def get_disk_type(identity, zone)
          disk_types = list_disk_types(zone).body['items']
          disk_type = disk_types.select { |dt| dt['name'] == identity } || []
          if disk_type.empty?
            return build_excon_response({
              'error' => {
                'errors' => [
                  {
                    'domain' => 'global',
                    'reason' => 'notFound',
                    'message' => "The resource 'projects/#{@project}/zones/#{zone}/diskTypes/#{identity}' was not found",
                  }
                ],
                'code' => 404,
                'message' => "The resource 'projects/#{@project}/zones/#{zone}/diskTypes/#{identity}' was not found",
              }
            })
          end

          build_excon_response(disk_type.first)
        end
      end

      class Real
        def get_disk_type(identity, zone)
          api_method = @compute.disk_types.get
          parameters = {
            'project'  => @project,
            'zone'     => zone.split('/')[-1],
            'diskType' => identity,
          }

          request(api_method, parameters)
        end
      end
    end
  end
end


text:
using Microsoft.VisualStudio.TestTools.UnitTesting;

namespace hexString.Tests {

    [TestClass]
    public class HexString_Immutability_Tests {

        [TestMethod]
        public void Bytes_Constructor_Argument_Cannot_Mutate() {
            var argument = new byte[] { 0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 };
            var hexString = new HexString(argument);
            argument[0] = 1;
            var bytes = hexString.ToBytes();
            Assert.AreNotEqual(argument[0], bytes[0]);
        }

        [TestMethod]
        public void Bytes_From_ToBytes_Cannot_Mutate() {
            var hexString =
                new HexString(new byte[] { 0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 });
            var notExpected = hexString.ToBytes();
            notExpected[0] = 1;
            var expected = hexString.ToBytes();
            Assert.AreNotEqual(notExpected[0], expected[0]);
        }
    }
}


text:
Q: Getting Exception java.lang.IllegalArgumentException in spark streaming scala mongodb fetch data I have the following code in Spark streaming scala to get data from kafka and insert into mongodb. Now I want to fetch the data from the mongodb but I am getting the Exception.How to get Data from MongoDb in spark streaming. Iam using scala 2.11.8 and spark version 2.3.2
val conf = new SparkConf().setMaster("local[*]").setAppName("KafkaExample")
      .set("spark.mongodb.input.uri", "mongodb://127.0.0.1/dbname.sensor_data")
      .set("spark.mongodb.output.uri", "mongodb://127.0.0.1/dbname.sensor_data")

 val ssc = new StreamingContext(conf, Seconds(120))

val lines = KafkaUtils.createDirectStream[String, String, StringDecoder, StringDecoder](
      ssc, kafkaParams, topics)
    lines.foreachRDD(rdd => {
      val spark = SparkSession
        .builder()
        .appName("IOTParser")
        .config("spark.mongodb.input.uri","mongodb://127.0.0.1/dbname.alert")
        .config("spark.mongodb.output.uri", "mongodb://127.0.0.1/dbname.alert")
        .getOrCreate()

 val alertDF = MongoSpark.load(spark)
println("Alert: " + alertDF.show(false)) //Getting an Exception here

})

Adding full exception stacktrace
2021-04-28 05:28:11 INFO  JobScheduler:54 - Finished job streaming job 1619587680000 ms.0 from job set of time 1619587680000 ms
2021-04-28 05:28:11 ERROR JobScheduler:91 - Error running job streaming job 1619587680000 ms.0
java.lang.IllegalArgumentException
    at org.apache.xbean.asm5.ClassReader.<init>(Unknown Source)
    at org.apache.xbean.asm5.ClassReader.<init>(Unknown Source)
    at org.apache.xbean.asm5.ClassReader.<init>(Unknown Source)
    at org.apache.spark.util.ClosureCleaner$.getClassReader(ClosureCleaner.scala:46)
    at org.apache.spark.util.FieldAccessFinder$$anon$3$$anonfun$visitMethodInsn$2.apply(ClosureCleaner.scala:449)
    at org.apache.spark.util.FieldAccessFinder$$anon$3$$anonfun$visitMethodInsn$2.apply(ClosureCleaner.scala:432)
    at scala.collection.TraversableLike$WithFilter$$anonfun$foreach$1.apply(TraversableLike.scala:733)
    at scala.collection.mutable.HashMap$$anon$1$$anonfun$foreach$2.apply(HashMap.scala:103)
    at scala.collection.mutable.HashMap$$anon$1$$anonfun$foreach$2.apply(HashMap.scala:103)
    at scala.collection.mutable.HashTable$class.foreachEntry(HashTable.scala:230)
    at scala.collection.mutable.HashMap.foreachEntry(HashMap.scala:40)
    at scala.collection.mutable.HashMap$$anon$1.foreach(HashMap.scala:103)
    at scala.collection.TraversableLike$WithFilter.foreach(TraversableLike.scala:732)
    at org.apache.spark.util.FieldAccessFinder$$anon$3.visitMethodInsn(ClosureCleaner.scala:432)
    at org.apache.xbean.asm5.ClassReader.a(Unknown Source)
    at org.apache.xbean.asm5.ClassReader.b(Unknown Source)
    at org.apache.xbean.asm5.ClassReader.accept(Unknown Source)
    at org.apache.xbean.asm5.ClassReader.accept(Unknown Source)
    at org.apache.spark.util.FieldAccessFinder$$anon$3$$anonfun$visitMethodInsn$2.apply(ClosureCleaner.scala:449)
    at org.apache.spark.util.FieldAccessFinder$$anon$3$$anonfun$visitMethodInsn$2.apply(ClosureCleaner.scala:432)
    at scala.collection.TraversableLike$WithFilter$$anonfun$foreach$1.apply(TraversableLike.scala:733)
    at scala.collection.mutable.HashMap$$anon$1$$anonfun$foreach$2.apply(HashMap.scala:103)
    at scala.collection.mutable.HashMap$$anon$1$$anonfun$foreach$2.apply(HashMap.scala:103)
    at scala.collection.mutable.HashTable$class.foreachEntry(HashTable.scala:230)
    at scala.collection.mutable.HashMap.foreachEntry(HashMap.scala:40)
    at scala.collection.mutable.HashMap$$anon$1.foreach(HashMap.scala:103)
    at scala.collection.TraversableLike$WithFilter.foreach(TraversableLike.scala:732)
    at org.apache.spark.util.FieldAccessFinder$$anon$3.visitMethodInsn(ClosureCleaner.scala:432)
    at org.apache.xbean.asm5.ClassReader.a(Unknown Source)
    at org.apache.xbean.asm5.ClassReader.b(Unknown Source)
    at org.apache.xbean.asm5.ClassReader.accept(Unknown Source)
    at org.apache.xbean.asm5.ClassReader.accept(Unknown Source)
    at org.apache.spark.util.FieldAccessFinder$$anon$3$$anonfun$visitMethodInsn$2.apply(ClosureCleaner.scala:449)
    at org.apache.spark.util.FieldAccessFinder$$anon$3$$anonfun$visitMethodInsn$2.apply(ClosureCleaner.scala:432)
    at scala.collection.TraversableLike$WithFilter$$anonfun$foreach$1.apply(TraversableLike.scala:733)
    at scala.collection.mutable.HashMap$$anon$1$$anonfun$foreach$2.apply(HashMap.scala:103)
    at scala.collection.mutable.HashMap$$anon$1$$anonfun$foreach$2.apply(HashMap.scala:103)
    at scala.collection.mutable.HashTable$class.foreachEntry(HashTable.scala:230)
    at scala.collection.mutable.HashMap.foreachEntry(HashMap.scala:40)
    at scala.collection.mutable.HashMap$$anon$1.foreach(HashMap.scala:103)
    at scala.collection.TraversableLike$WithFilter.foreach(TraversableLike.scala:732)
    at org.apache.spark.util.FieldAccessFinder$$anon$3.visitMethodInsn(ClosureCleaner.scala:432)
    at org.apache.xbean.asm5.ClassReader.a(Unknown Source)
    at org.apache.xbean.asm5.ClassReader.b(Unknown Source)
    at org.apache.xbean.asm5.ClassReader.accept(Unknown Source)
    at org.apache.xbean.asm5.ClassReader.accept(Unknown Source)
    at org.apache.spark.util.ClosureCleaner$$anonfun$org$apache$spark$util$ClosureCleaner$$clean$14.apply(ClosureCleaner.scala:262)
    at org.apache.spark.util.ClosureCleaner$$anonfun$org$apache$spark$util$ClosureCleaner$$clean$14.apply(ClosureCleaner.scala:261)
    at scala.collection.immutable.List.foreach(List.scala:381)
    at org.apache.spark.util.ClosureCleaner$.org$apache$spark$util$ClosureCleaner$$clean(ClosureCleaner.scala:261)
    at org.apache.spark.util.ClosureCleaner$.clean(ClosureCleaner.scala:159)
    at org.apache.spark.SparkContext.clean(SparkContext.scala:2299)
    at org.apache.spark.rdd.RDD$$anonfun$map$1.apply(RDD.scala:371)
    at org.apache.spark.rdd.RDD$$anonfun$map$1.apply(RDD.scala:370)
    at org.apache.spark.rdd.RDDOperationScope$.withScope(RDDOperationScope.scala:151)
    at org.apache.spark.rdd.RDDOperationScope$.withScope(RDDOperationScope.scala:112)
    at org.apache.spark.rdd.RDD.withScope(RDD.scala:363)
    at org.apache.spark.rdd.RDD.map(RDD.scala:370)
    at com.mongodb.spark.sql.MongoRelation.buildScan(MongoRelation.scala:58)
    at org.apache.spark.sql.execution.datasources.DataSourceStrategy$$anonfun$10.apply(DataSourceStrategy.scala:293)
    at org.apache.spark.sql.execution.datasources.DataSourceStrategy$$anonfun$10.apply(DataSourceStrategy.scala:293)
    at org.apache.spark.sql.execution.datasources.DataSourceStrategy$$anonfun$pruneFilterProject$1.apply(DataSourceStrategy.scala:338)
    at org.apache.spark.sql.execution.datasources.DataSourceStrategy$$anonfun$pruneFilterProject$1.apply(DataSourceStrategy.scala:337)
    at org.apache.spark.sql.execution.datasources.DataSourceStrategy.pruneFilterProjectRaw(DataSourceStrategy.scala:415)
    at org.apache.spark.sql.execution.datasources.DataSourceStrategy.pruneFilterProject(DataSourceStrategy.scala:333)
    at org.apache.spark.sql.execution.datasources.DataSourceStrategy.apply(DataSourceStrategy.scala:289)
    at org.apache.spark.sql.catalyst.planning.QueryPlanner$$anonfun$1.apply(QueryPlanner.scala:63)
    at org.apache.spark.sql.catalyst.planning.QueryPlanner$$anonfun$1.apply(QueryPlanner.scala:63)
    at scala.collection.Iterator$$anon$12.nextCur(Iterator.scala:434)
    at scala.collection.Iterator$$anon$12.hasNext(Iterator.scala:440)
    at scala.collection.Iterator$$anon$12.hasNext(Iterator.scala:439)
    at org.apache.spark.sql.catalyst.planning.QueryPlanner.plan(QueryPlanner.scala:93)
    at org.apache.spark.sql.catalyst.planning.QueryPlanner$$anonfun$2$$anonfun$apply$2.apply(QueryPlanner.scala:78)
    at org.apache.spark.sql.catalyst.planning.QueryPlanner$$anonfun$2$$anonfun$apply$2.apply(QueryPlanner.scala:75)
    at scala.collection.TraversableOnce$$anonfun$foldLeft$1.apply(TraversableOnce.scala:157)
    at scala.collection.TraversableOnce$$anonfun$foldLeft$1.apply(TraversableOnce.scala:157)
    at scala.collection.Iterator$class.foreach(Iterator.scala:893)
    at scala.collection.AbstractIterator.foreach(Iterator.scala:1336)
    at scala.collection.TraversableOnce$class.foldLeft(TraversableOnce.scala:157)
    at scala.collection.AbstractIterator.foldLeft(Iterator.scala:1336)
    at org.apache.spark.sql.catalyst.planning.QueryPlanner$$anonfun$2.apply(QueryPlanner.scala:75)
    at org.apache.spark.sql.catalyst.planning.QueryPlanner$$anonfun$2.apply(QueryPlanner.scala:67)
    at scala.collection.Iterator$$anon$12.nextCur(Iterator.scala:434)
    at scala.collection.Iterator$$anon$12.hasNext(Iterator.scala:440)
    at org.apache.spark.sql.catalyst.planning.QueryPlanner.plan(QueryPlanner.scala:93)
    at org.apache.spark.sql.execution.QueryExecution.sparkPlan$lzycompute(QueryExecution.scala:72)
    at org.apache.spark.sql.execution.QueryExecution.sparkPlan(QueryExecution.scala:68)
    at org.apache.spark.sql.execution.QueryExecution.executedPlan$lzycompute(QueryExecution.scala:77)
    at org.apache.spark.sql.execution.QueryExecution.executedPlan(QueryExecution.scala:77)
    at org.apache.spark.sql.Dataset.withAction(Dataset.scala:3254)
    at org.apache.spark.sql.Dataset.head(Dataset.scala:2489)
    at org.apache.spark.sql.Dataset.take(Dataset.scala:2703)
    at org.apache.spark.sql.Dataset.showString(Dataset.scala:254)
    at org.apache.spark.sql.Dataset.show(Dataset.scala:725)
    at org.apache.spark.sql.Dataset.show(Dataset.scala:702)
    at com.agreeya.iot.IOTDataParser$$anonfun$main$1.apply(IOTDataParser.scala:156)
    at com.agreeya.iot.IOTDataParser$$anonfun$main$1.apply(IOTDataParser.scala:38)
    at org.apache.spark.streaming.dstream.DStream$$anonfun$foreachRDD$1$$anonfun$apply$mcV$sp$3.apply(DStream.scala:628)
    at org.apache.spark.streaming.dstream.DStream$$anonfun$foreachRDD$1$$anonfun$apply$mcV$sp$3.apply(DStream.scala:628)
    at org.apache.spark.streaming.dstream.ForEachDStream$$anonfun$1$$anonfun$apply$mcV$sp$1.apply$mcV$sp(ForEachDStream.scala:51)
    at org.apache.spark.streaming.dstream.ForEachDStream$$anonfun$1$$anonfun$apply$mcV$sp$1.apply(ForEachDStream.scala:51)
    at org.apache.spark.streaming.dstream.ForEachDStream$$anonfun$1$$anonfun$apply$mcV$sp$1.apply(ForEachDStream.scala:51)
    at org.apache.spark.streaming.dstream.DStream.createRDDWithLocalProperties(DStream.scala:416)
    at org.apache.spark.streaming.dstream.ForEachDStream$$anonfun$1.apply$mcV$sp(ForEachDStream.scala:50)
    at org.apache.spark.streaming.dstream.ForEachDStream$$anonfun$1.apply(ForEachDStream.scala:50)
    at org.apache.spark.streaming.dstream.ForEachDStream$$anonfun$1.apply(ForEachDStream.scala:50)
    at scala.util.Try$.apply(Try.scala:192)
    at org.apache.spark.streaming.scheduler.Job.run(Job.scala:39)
    at org.apache.spark.streaming.scheduler.JobScheduler$JobHandler$$anonfun$run$1.apply$mcV$sp(JobScheduler.scala:257)
    at org.apache.spark.streaming.scheduler.JobScheduler$JobHandler$$anonfun$run$1.apply(JobScheduler.scala:257)
    at org.apache.spark.streaming.scheduler.JobScheduler$JobHandler$$anonfun$run$1.apply(JobScheduler.scala:257)
    at scala.util.DynamicVariable.withValue(DynamicVariable.scala:58)
    at org.apache.spark.streaming.scheduler.JobScheduler$JobHandler.run(JobScheduler.scala:256)
    at java.base/java.util.concurrent.ThreadPoolExecutor.runWorker(ThreadPoolExecutor.java:1128)
    at java.base/java.util.concurrent.ThreadPoolExecutor$Worker.run(ThreadPoolExecutor.java:628)
    at java.base/java.lang.Thread.run(Thread.java:834)
2021-04-28 05:28:16 INFO  MongoClientCache:48 - Closing MongoClient: [127.0.0.1:27017]

redpajama_set_name: RedPajamaStackExchange


text:
British GP Services Under Examination
Independent British health charity The King's Fund has launched a nationwide, 18-month inquiry into the quality of general practitioner (GP) services. The inquiry will examine key areas like access to care, the quality of diagnosis and referrals, drug prescription and how people with long
Independent British health charity The King's Fund has launched a nationwide, 18-month inquiry into the quality of general practitioner (GP) services.
The inquiry will examine key areas like access to care, the quality of diagnosis and referrals, drug prescription and how people with long-term conditions are cared for.
It will also focus on delays in testing for certain cancers, and diagnosis, especially among older patients.
The inquiry will examine high-quality care to define the role of GPs and general practice in the delivery of that care in order to make recommendations on how it should be measured.
The inquiry has been launched amid nationwide opposition from general practitioners, according to the national press.
By staff writer.


text:
Ryn Gargulinski
Creativity on Fire
Shots fired at parks and wildlife crew on the border
Men and women in uniform may look official, snappy and, depending on the uniform, sometimes even sexy, but they are also easy targets for gun-toting Mexicans along the border.
It doesn't matter if the uniform denotes Border Patrol, cops or even a wildlife or parks worker.
Game and Fish officer, 2 other agency employees fired upon near Mexico border, AZ Game and Fish Dept. news release:
PHOENIX – Three government agency employees, including an officer with the Arizona Game and Fish Department, another Game and Fish employee, and an employee with Pima County Natural Resources, Parks and Recreation, were fired upon the afternoon of June 11 by a group of men they encountered while scouting the area for a land access project in southern Arizona.
None of the agency employees were injured.
The three were riding all-terrain vehicles (ATVs) on a road through a small canyon area about four miles east of Arivaca Lake when they encountered a group described as at least four Hispanic males dressed in camouflage.
According to Leonard Ordway, supervisor for Game and Fish's Tucson region, two of the individuals in camouflage immediately fled a short distance up a hill and dropped down in the grass upon the encounter, while the agency employees backed out of the immediate vicinity and regrouped.
After a few minutes, the Game and Fish officer crept up a small rise a short distance from the road to look over the scene with binoculars. He observed two other males in camouflage in the area, but in a different direction from the first two. He then started back down the hill to return to the ATVs.
"As he started back down to the quads, a gunshot coming from the direction where the first two individuals had fled impacted the ground about 10 feet behind him," said Ordway.
The three agency employees immediately departed the area and notified Game and Fish Radio Dispatch, which in turn notified the Border Patrol, Pima County Sheriff's Office, and the Arizona Department of Public Safety.
About 30-40 law enforcement personnel, aided by three helicopters, were on site within 45 minutes to search the area and investigate the scene. They were not able to find the suspects but did recover several fresh 9mm casings from the area where the initial shot came from, indicating subsequent shots may have been fired as the agency employees were leaving the area.
"We're thankful no one was hurt," said Game and Fish Director Larry Voyles. "Our law enforcement officers and other field personnel often work in remote areas, and (this) incident serves as a reminder of the potential dangers that they—and personnel from other agencies—face in areas near the border."
Voyles added that Game and Fish is reviewing its operating procedures for employees working in borderland areas.
Maybe parks, wildlife and natural resources employees along the border can change their uniforms to something less official-looking, like cut-offs and tank tops. But was it the uniforms that helped prompt the shooting or would the men have shot at anything that moved?
follow rynski:
Filed Under: blogski, crime, danger, environment, immigrants Tagged With: angry, border, immigrants, mexicans, shots
nevadademocrat says
I think the gunmen would have killed, or tried to kill, anyone less well armed than themselves they happened across.
Go well armed, shoot back, make it count. If you surrender, you will most likely die out there at their hands, just as with western captives of the medieval-minded Islamic Fundamentalists in Iraq.
RADC MAXIMUS says
"Voyles added that Game and Fish is reviewing its operating procedures for employees working in borderland areas." Ya think?