text:
Uterosacral Shelf For Cystocele Repair
Laparoscopic Management Of Para-Ovarian Cyst Torsion With 20-Week Pregnancy
Bhate A, Joshi D, Chitnis S.
Deranged Liver Enzymes In A Case Of Diabetes In Pregnancy: Diagnostic Dilemma
Saxena A, Thunga C, Madhva Prasad S, Gupta AS.
Lateral Approach To Hemihematometra
Shetty A, Madhva Prasad S, Gupta AS.
An Unusual Case Of Placenta Increta
Mehta N, Honavar P, Parulekar SV.
Laparoscopic Management Of Non Communicating Rudimentary Horn Pregnancy
Shah NH, Deshmukh M, Somani A, Paranjpe SH.
Successful Management Of H1N1 Infection Complicating A Case Of Twin Pregnancy With Eclampsia
Kambhampati L, More V.
Pregnancy In A Post Renal Transplant Patient
Shah S, Warke H, Mayadeo N.
Rare Case Of Stickler's Syndrome
Dhanawat J, Uppal M, Samant PY.
Genital prolapse was known to Hippocrates and Galen, in whose writings it finds a place. The exact pathophysiology of the condition was not known then. But it was known that it caused a significant deterioration of the quality of life. Hence attempts were made to repair it. The earliest attempts were simple. Pessaries were used as trusses to control the symptoms of prolapse in the middle of the nineteenth century. Earliest surgical attempts included suturing the opposite side labia together in the midline, and removing a part of the vagina to narrow its width. First operation on the anterior vaginal wall was done by Heming in 1831. Modern techniques of colporrhaphy were being used and reported in the early part of the 20th century. Howard Kelly from Baltimore promoted the plication of pubovesicocervical fascia in the midline for repair of a cystocele. It was assumed that endopelvic fascial support structures got damaged during childbirth causing vaginal wall prolapse. Kelly's plication of the fascia was based on that concept. This concept remained strong almost throughout the 20th century. A major breakthrough came with identification and classification of fascial defects as proximal, distal, central, and lateral by Richardson et al from Georgia. It was found that the endopelvic fascia invested and supported all the pelvic organs. It connected the pelvic organs to the retropubic fascia, fascia on the lateral pelvic walls (obturator fascia, in which a condensation was present to form the arcus tendineus fasciae pelvis), and pelvic floor (formed by the levatores ani). It was condensed to form uterosacral and cardinal ligaments which were connected to the pericervical ring. DeLancey further showed that the proximal one third of the vagina was suspended by the uterosacral ligaments, the middle one third was supported by lateral attachments to the pelvic side wall at the arcus tendineus fasciae pelvis and the distal one third of the anterior vagina was fused with the urogenital diaphragm. Damage to the fascial attachments to the middle one third of vagina resulted in paravaginal defects. Damage to the fascial attachments between the vagina and the uterosacral-cardinal ligament complexes resulted in central transverse defects. These concepts have become very important in site-specific repairs. It is now found that the plication procedure for repair of a cystocele bunches the endopelvic connective tissue in the midline, which places more stress on paravaginal defects by pulling the detached edge of the fascia away from the pelvic side wall and aggravates the prolapse. As a result, the failure rates are unacceptably high, and there are functional disturbances of micturition too. In more recent times, owing to perhaps a desire to keep doing something new or perhaps due to a marketing strategy of manufacturers of synthetic meshes, there has been growing interest in using meshes under the vagina to provide support to it. Subsequently there have been reports of mesh erosion and other problems and a trend towards not using meshes. Perhaps litigations by patients discouraged doctors. Manufacturers inserted a statement warning about the complications of meshes and asking the doctors to use the product at their own discretion. Perhaps it removed the responsibility from them to the doctors, which discouraged the use of meshes even further. In the meantime, we have been using site specific repair with excellent results and did not have to resort to the use of meshes. In this issue of the journal, we have a report of an innovative operation in which the uterosacral ligament pedicles were placed under the bladder base to support it. If one thinks about it, one realizes it is one form of a site specific repair, since the end result is bladder fascia being attached to the uterosacral ligaments. I hope the readers benefit from this article and enjoy this issue like the previous ones.
(Professor and Head, Department of Obstetrics and Gynecology, Seth G S Medical College & KEM Hospital, Mumbai, India.)
Approximately 11% of women will undergo pelvic reconstructive surgery for pelvic organ prolapse and/or urinary incontinence during their lifetime. Cystocele in women is one of the common problems associated with uterovaginal prolapse. It occurs when the fascia between urinary bladder and vagina is weakened allowing the bladder to herniate into the vagina. While usually not lifethreatening, cystocele is often associated with deterioration in quality of life and may contribute to bladder and sexual dysfunction. It was conventionally repaired by plication of the pubovesicocervical fascia from the right and left sides in the midline. The next step in its evolution was site specific repair, in which the type of defect in the fascia was repair instead of plicating the fascia indiscriminately. The third step was use of biological and synthetic meshes. However the meshes have their own problems and complications. A novel approach of using the uterosacral ligaments to perform a cystocele repair after a vaginal hysterectomy is described here.
Genital prolapse in women was known to Hippocrates and Galen. Heming first operated on the anterior vaginal wall in 1831. Howard Kelly of Baltimore championed the concept of plication of pubovesicocervical fascia in the midline for repair of a cystocele.[1] In 1909, George R. White of Georgia published an account of cystocele repair using a transvaginal paravaginal approach.[1,2] A. Cullen Richardson and associates of Georgia developed the concept of classifying fascial defects as proximal, distal, central, and lateral.[2,3] This encouraged gynecologists to identify and repair each vaginal defect and to return support attachments to their original anatomic location. Emphasis was focused on he hernial nature of prolapse and led to the abandonment of absorbable suture in favor of permanent suture in repairs.[4-8] The results of site specific repair of a cystocele are far superior to those of plication of the fascia.[9-12] Postoperative complications and urinary disturbances are also much less. Subsequently the trend has been moving towards use of biological or synthetic meshes for the repair. Meshes behave differently in the subvaginal space than in the abdominal wall. Infection, erosion and extrusion rates are higher and so is the risk of litigation. We prefer a site specific repair to the use of a mesh. In case the fascia is too weak to be repaired adequately to provide a satisfactory repair, the uterosacral ligaments may be used to provide the required support to the urinary bladder. A novel approach of using the uterosacral ligaments to perform a cystocele repair after a vaginal hysterectomy is described here.
Operative Technique
While performing the vaginal hysterectomy, the uterosacral ligaments are clamped, cut and ligated quite close to the uterus, so that maximum possible lengths of the ligaments is made available for use during anterior colporrhaphy. One end of a ligature on each ligament is kept long and held with a hemostat.
Epinephrine in saline (1:300000) is infiltrated under the vaginal mucosa overlying the cystocele.
A midline incision is made in the anterior vagina overlying the cystocele.
A flap of the anterior vagina are raised on each side by sharp dissection, separating the vagina from the fascia overlying the urinary bladder.
The dissection is carried out laterally up to the white lines on the two sides.
Hemostasis is achieved. This is important, as a failure to do so may result in formation of a hematoma between the urinary bladder and the uterosacral ligaments fixed below it. Infection in the hematoma would result in formation of an abscess and its complications.
The uterosacral ligaments are fixed under the urinary bladder.
Two sutures of No. 1 polyglactin are passed through the terminal cut part of each ligament. They are then passed through the vagina lateral to the urethra. When the sutures are tied on each side, the ligaments get fixed under the urinary bladder.
The gap between the two uterosacral ligaments is closed with interrupted sutures of No. 1-0 polypropylene passed through adjacent edges of the ligaments.
Lateral edge of each uterosacral ligament is sutured to the white line of that side with interrupted sutures of No. 1-0 polypropylene.
Redundant part of the vaginal mucosa is excised. The vaginal edges are sutured to each other in midline with interrupted sutures of No. 1-0 polyglactin.
The center of the vault of the vagina is suspended from the uterosacral ligaments in midline with a suture of No. 1-0 polyglactin.
The transverse edge of the anterior vagina is sutured to the transverse edge of the posterior vagina with interrupted sutures of No. 1-0 polyglactin.
Figure 1. Anterior colporrhaphy dissection has been done. The urinary bladder (UB), left uterosacral ligament (LUSL) and the right uterosacral ligament (RUSL) are seen.
Figure 2. No. 1 polyglactin ligature on the RUSL is threaded on a curved needle.
Figure 3. The cystocele is reduced by pressure of a finger.
Figure 4. The RUSL ligament is drawn forward along the right side of the urethra.
Figure 5. The needle is passed through the right flap of the vaginal mucosa, from inside out, at the level a little posterior to the external urinary meatus.
Figure 6. Another suture of No. 1 polyglactin suture is passed through the terminal part of the RUSL and tied.
Figure 7. The suture is passed through the right flap of the vaginal mucosa, from inside out, 5 mm away from the first suture.
Figure 8. The LUSL ligament (arrows) is drawn forward along the left side of the urethra.
Figure 9. No. 1 polyglactin ligature on the LUSL is threaded on a curved needle.
Figure 10. The needle is passed through the left flap of the vaginal mucosa, from inside out, at the same level as the first suture on the right side.
Figure 11. Another suture of No. 1 polyglactin suture is passed through the terminal part of the LUSL and tied. It is passed through the left flap of the vaginal mucosa, from inside out, 5 mm away from the previous suture.
Figure 12. The two sutures on the left side are tied on the external surface of the left flap of vaginal mucosa. The sutures on the right side are tied similarly.
Figure 13. The RUSL (black arrows) and LUSL (white arrows) are seen to be drawn forwards under the base of the urinary bladder.
Figure 14. The two uterosacral ligaments are approximated in the midline with interrupted sutures of No. 1-0 polypropylene.
Figure 15. Approximation of the two uterosacral ligaments in the midline is complete.
Figure 16. The gap between the LUSL and left lateral pelvic wall is demonstrated by passing a finger between the two.
Figure 17. The left edge of the LUSL is sutured to the left white line with interrupted sutures of No. 1-0 polypropylene.
Figure 18. The right edge of the RUSL is sutured to the right white line with interrupted sutures of No. 1-0 polypropylene.
Figure 19. The end result: the two uterosacral ligaments have been sutured to each other in midline, and each one has been sutured to the white line of the respective side laterally.
Pelvic endopelvic fascia is fibroelastic connective tissue matrix with varying amounts of smooth muscle. It covers all the pelvic organs It fills the space between the pelvic diaphragm, the pelvic sidewall, and the visceral peritoneum. The endopelvic fascia covering the obturator internus is called as the obturator fascia. It is well defined in the arcus tendineus fascia pelvis (white line). It is condensed to form the pubocervical ligaments, which are attached to the under surface of the superior pubic ramus, the arcus tendineus fascia pelvis and the pericervical ring. This insertion is continuous with and forms part of the pericervical ring. The pubovesicocervical fascia is attached to the pubic tubercles, the pubic arch, the urogenital diaphragm, the white line, the pericervical ring and the cardinal ligaments. It is continuous with the fascia over the urinary bladder and the vagina. Continuity of the fascia, the uterosacral-cardinal ligament complex and vesical fascia is essential for keeping the bladder supported.[1,2] If the fascia gets detached from the white line, a lateral cystocele develops.[9] If it gets separated from the pericervical ring and the uterosacral-cardinal cardinal ligament complex, a central transverse type of cystocele develops.[9] Identification of these defects is easy clinically and during anterior colporrhaphy.
If the endopelvic fascia is too weak, a site specific repair does not often work because there is no specific defect located at any particular site, but all the fascia is weak. In such situation, if the uterosacral-cardinal ligaments are thick, they can be used to support the urinary bladder. In the new operation described here, the uterosacral ligaments are carried forward in the same direction in which they are present normally. That becomes possible because they are lengthened due to genital prolapse. Since they originate from the same endopelvic fascia, being its condensed parts, they can be used effectively for the repair of the cystocele. When they are joined to each other in the midline and fixed under the urinary bladder, they provide a strong and wide shelf for the urinary bladder to rest on. There are gaps between the sides of the ligaments and the obturator fascia, and if these are not occluded, the patient may present with uni- or bilateral cystocele. These gaps are closed by suturing the lateral edges of the uterosacral ligaments to the white lines of the respective sides. This results in reestablishment of continuity of fascia between the white lines laterally and uterosacral ligaments posteriorly. Provision of such a strong support with endogenous tissue does away with the need for synthetic meshes and possibility of complications associated with their use.
Milley PS, Nichols DH. The relationship between the pubocervical ligaments and the urogenital diaphragm in the human female. Anat Rec. 1969;163:433.
Richardson AC, Lyon JB, Williams NL. A new look at pelvic relaxation. Am J Obstet Gynecol 1976;126:568.
Richardson AC. Female pelvic floor support defects. Int Urogynecol J Pelvic Floor Dysfunct I 996;7(5):241.
DeLancey JO. Pelvic organ prolapse: clinical management and scientific foundations. Clin Obstet Gynecol 1993;36:895.
Johnston SL, Low JA. Anterior colporrhaphy. In Drutz HP, Herschorn S, Diamant NE. Eds Female Pelvic Medicine and Reconstructive Pelvic Surgery. 1st edition. London. Springer. 2017. pp 329-337.
Karram MM. Vaginal operations for prolapse. In: Baggish MS, Karram MM, eds. Atlas of Anatomy and Gynecologic Surgery. Philadelphia: WB Saunders, 2001:394.
Weber AM, Walters MD. Anterior vaginal prolapse: review of anatomy and techniques of surgical repair. Obstet Gynecol 1997;89:311.
Kovac SR, Stubbs JTF. Repair of the Anterior Segment. in Advances in Reconstructive Vaginal Surgery. Kovac SR; Zimmerman CW. eds. Lippincott Williams & Wilkins. 1st Edition. 2007. pp 470-551.
Zimmerman CW. New concepts in restoration of the anterior vaginal compartment. Operative Techniques in Gynecologic Surgery 2001;6:116.
Link G, van Dooren IM, Wieringa NM. The extended reconstruction of the pubocervical layer appears superior to the simple plication of the bladder adventitia concerning anterior colporrhaphy: a description of two techniques in an observational retrospective analysis. Gynecol Obstet Invest 2011;72(4):274-280.
Morse AN, O'dell KK, Howard AE, Baker SP, Aronson MP, Young SB. Midline anterior repair alone vs anterior repair plus vaginal paravaginal repair: a comparison of anatomic and quality of life outcomes. Int Urogynecol J Pelvic Floor Dysfunction. 2007;18:245-9.
Hosni MM, El-Feky AEH, Agur WI, Khater EM. Evaluation of three different surgical approaches in repairing paravaginal support defects: a comparative trial. Arch Gynecol Obstet 2013;288(6):1341–1348.
Parulekar SV. Uterosacral Shelf For Cystocele Repair. JPGO 2017. Volume 4 No.10. Available from: http://www.jpgo.org/2017/10/uterosacral-shelf-for-cystocele-repair.html
Bhate A*, Joshi D** , Chitnis S***.
(* Director, Shubhdeep Nursing Home, Andheri, Mumbai, ** Consultant, Leela Joshi Hospital, Bhiwandi, Thane, *** Consultant, Department of Obstetrics & Gynaecology, MaxCure Superspeciality, Jogeshwari, Mumbai, India.)
Adnexal torsion (AT) in pregnancy is a rare condition which presents as an acute abdomen. The diagnosis may be missed because of accompanying non-specific signs and symptoms. Diagnostic laparoscopy followed by detorsion and cystectomy, offer fair chances of saving the adnexa as well as facilitate early recovery. We present a case of acute torsion of a large para-ovarian cyst which was treated by laparoscopy, where both ovary and fallopian tube could be preserved.
Adnexal torsion remains a rare emergency which eludes diagnosis. It must be considered as a differential diagnosis in pregnant patients presenting with acute pelvic pain.[1] It has similar presentation in pregnant and non-pregnant women, although underlying pathology may be different. There has been an observation that majority of cases in pregnancy are associated with functional cysts.[2] Torsion during pregnancy occurs primarily in the first or the second trimester.[3] Torsion in pregnancy is increasingly being reported due to liberal use of ultrasound in pregnancy, which also happens to be the most valuable tool in diagnosis of torsion. Earlier, all cases were treated by laparotomy and adnexectomy. This now has been popularly replaced by laparoscopy due to its associated safety, faster recovery and minimal risk to the fetus.
A 23 year old primigravida visited antenatal clinic for the first time with 5 months of amenorrhea associated with pain in abdomen. Pain was dull aching in nature, non-radiating and aggravated by activity. She had no other complaints such as vomiting or fever. She had conceived spontaneously and had an uneventful pregnancy so far. She appeared pale but had stable vital parameters. Uterine height corresponded to 24 weeks of gestation. She was admitted and started on intravenous isoxsuprine and micronized progesterone. Investigations revealed iron deficiency anemia and leucocytosis (hemoglobin of 7.6 g/dL and white blood cell count of 12,300/cmm). Her liver and renal function tests, urine routine and quadruple markers were normal. Ultrasound scan for anomalies was done. It showed a 19-20 weeks' fetus in changing lie with prominent renal pelvis. A simple cyst of 10.4x7.2 cm was noted in the left adnexa with scanty flow in pedicle. Bilateral ovaries were seen separately and were normal in size. She had not undergone any investigations in the past, thereby the duration of adnexal mass could not be determined. Diagnosis of left adnexal torsion was made and decision for performing a laparoscopy was taken.
She was transfused with 1 unit of packed cells prior to surgery. Peritoneal access was gained with supraumbilical port and lateral ports under general anesthesia. Port placement was higher than usual in order to prevent injury to the uterus. Upon entry into the abdomen, a left para-ovarian cyst with single twist of its pedicle was noted. Fallopian tube was stretched over the cyst. The left ovary was normal. Right ovary and fallopian tube were normal. Pedicle was derotated and cyst was enucleated. Cyst contents (clear straw colored fluid) were drained. It was a simple cyst with no solid component. The excised cyst wall was sent for histopathology. There was no compromise to ipsilateral fallopian tube and ovary. Post-operatively, the patient recovered uneventfully with no obstetric complications.
Figure 1. Gravid uterus (U) and the paraovarian cyst (C).
Figure 2. Gravid uterus (U) and the paraovarian cyst (C), Ovary (O), Tube (T).
Figure 3. Retracting the gravid uterus.
Figure 4. Incision for enucleating the cyst.
Adnexal masses may be found in 0.19-8.8% of all pregnancies.[4] Adnexal torsion is an emergency which warrants early diagnosis and treatment to prevent complications. A low incidence of 1-5 per 10000 pregnancies makes it a diagnostic dilemma.[5] Incidence of adnexal torsion rises considerably in pregnancies achieved after assisted reproductive techniques.[6] Medial torsion while considering infundibulopelvic ligament as the reference point has an overall higher incidence. In pregnancy however, lateral torsion is not uncommon and may be seen in as high as 35.6% women.[7] Symptoms are commonly non-specific, with pelvic pain being the commonest complaint. The patient may also have nausea, vomiting and fever. White blood cell count is frequently elevated. Outcome of pregnancy is variable and depends on gestational age.[8]
Ultrasound is the most commonly used diagnostic tool. Presence of symptoms (nausea and vomiting), elevated leukocytes and ovarian cyst > 5 cm in diameter are indicative of torsion and aid in diagnosis. Magnetic resonance imaging may be used to aid diagnosis in doubtful cases.
Several approaches have been used for surgical intervention in adnexal torsion, e.g., laparotomy (Pfannenstiel, midline vertical incision or para-rectal incision).[9] Laparoscopy is a reasonably safe technique for establishing diagnosis and treatment in the same sitting.[4] It may be carried out in any trimester with minimum risk to mother and fetus, although peritoneal entry may be problematic in advanced gestation.[10] Entry through Palmar's space, located in the mid clavicular line 3 cm below the coastal margin, is a suitable alternative in such cases.[11] This approach is especially useful in cases where problems are anticipated in umbilical entry, as in presence of large fibroid, peritoneal adhesions and as in our case an enlarged gravid uterus. Entry may be made by Veress' needle or small sized trocar and cannula. Our patient presented with pain in abdomen. She was admitted and swiftly investigated to reveal a large adnexal cyst with reduced flow in the pedicle along with anemia and leukocytosis. Peritoneal access during laparoscopy was a concern, hence supraumbilical port was placed 3-4 cm above the usual location. Lateral ports were placed under vision.
Adnexal torsion in pregnancy is rare and clinical diagnosis is difficult due to vague symptoms and signs. Doppler ultrasound is a useful tool to diagnose torsion by detecting absence or presence of vascularity in the pedicle. It is also helpful in assessing whether the patient needs adnexectomy.[12] Laparoscopy can be safely used for treatment of adnexal torsion with good surgical and obstetric outcomes. It also has the advantage of less discomfort and early recovery.[8] In advanced gestation entry through Palmar's point or open laparoscopy may be preferred in order to avoid penetrative injuries. Early surgical intervention in adnexal torsion is the key to prevent loss of vascularity in adnexae. Adnexectomy can be prevented by timely treatment of torsion.
Bouguizane S, Bibi H, Farhat Y, Dhifallah S, Darraji F, Hidar S, et al. [Adnexal torsion: a report of 135 cases]. J Gynecol Obstet Biol Reprod (Paris). France; 2003 Oct;32(6):535–40.
Melcer Y, Sarig-Meth T, Maymon R, Pansky M, Vaknin Z, Smorgick N. Similar But Different: A Comparison of Adnexal Torsion in Pediatric, Adolescent, and Pregnant and Reproductive-Age Women. J Womens Health (Larchmt). 2016;25(4):391–6.
Fouedjio JH, Fouogue JT, Fouelifack FY, Nangue C, Sando Z, Mbu RE. [Torsion of uterine appendages during pregnancy: report of a case at Yaounde Central Hospital, Cameroon]. Pan Afr Med J. Uganda; 2014;17:39.
Cavaco-Gomes J, Moreira CJ, Rocha A, Mota R, Paiva V, Costa A. Investigation and Management of Adnexal Masses in Pregnancy. Scientifica (Cairo).2016;2016:3012802.
Bras R, Braga J, Tome A, Ferreira H. Adnexal Torsion in the First Trimester of Pregnancy: Diagnosis, Laparoscopic Management, and Review of the Literature. Surg Technol Int.2017;30:210–4.
Hasson J, Tsafrir Z, Azem F, Bar-On S, Almog B, Mashiach R, et al. Comparison of adnexal torsion between pregnant and nonpregnant women. Am J Obstet Gynecol. 2010 ;202(6):536.e1-6.
Krissi H, Hiersch L, Aviram A, Ashwal E, Goldschmit C, Peled Y. Factors Affecting Adnexal Torsion Direction: A Retrospective Cohort Study. Gynecol Obstet Invest. 2016;81(5):405–10.
Chang S-D, Yen C-F, Lo L-M, Lee C-L, Liang C-C. Surgical intervention for maternal ovarian torsion in pregnancy. Taiwan J Obstet Gynecol.2011;50(4):458–62.
Basaranoglu S, Agacayak E, Tune SY, Icen MS, Turgut A, Peker N, et al. Clinical experience in pregnancies complicated by adnexal torsion. Clin Exp Obstet Gynecol. 2016;43(3):345–9.
Weiner E, Mizrachi Y, Keidar R, Kerner R, Golan A, Sagiv R. Laparoscopic surgery performed in advanced pregnancy compared to early pregnancy. Arch Gynecol Obstet. 2015;292(5):1063–8.
Ramcharan P, Flynn M, Berkshire Grant G. You have to prove yourself all the time: People with learning disability. In: Grant G, Goward P, Richardson M and Paul Ramcharan P editors. Learning Disability: A life cycle approach. 2nd ed. England. McGraw -Hill Education. Open University Press. 2010; p. 311–28.
Arena S, Canonico S, Luzi G, Epicoco G, Brusco GF, Affronti G. Ovarian torsion in in vitro fertilization-induced twin pregnancy: combination of Doppler ultrasound and laparoscopy in diagnosis and treatment can quickly solve the case. Fertil Steril 2009;92(4):1496(e9-13).
Bhate A, Joshi D, Chitnis S. Laparoscopic Management Of Para-Ovarian Cyst Torsion With 20-Week Pregnancy. JPGO 2017. Volume 4 No. 10. Available from: http://www.jpgo.org/2017/10/laparoscopic-management-of-para-ovarian.html
Saxena A*, Thunga C**, Madhva Prasad S***, Gupta AS****.
(* First year Resident, ** Senior Resident, *** Assistant Professor, **** Professor, Department of Obstetrics and Gynecology, Seth GS Medical College and KEM Hospital, Mumbai.)
A case of a pregnancy with diabetes mellitus and incidental finding of deranged liver enzymes and the diagnostic dilemma associated with such a condition is presented here. A brief discussion of the possibilities is presented.
Diabetes in pregnancy can be classified as those known to have diabetes prior to pregnancy, pre gestational or overt diabetes; and those diagnosed during pregnancy, gestational diabetes mellitus. Classification of non pregnant individuals with diabetes is based on the presumed etiopathogenesis and pathological manifestations, broadly as Type 1 diabetes with absolute insulin deficiency and Type 2 diabetes with insulin resistance. Most of the gestational diabetic women are likely to have Type 2 diabetes which had been undiagnosed till pregnancy.[1]
Concern is mainly due to the complications associated with diabetes in pregnancy, both maternal and fetal morbidity and mortality. Most of them present with deranged blood sugar levels and no symptoms. Some present with complications like ketoacidosis, hypoglycemia, hypertension, infections, pre eclampsia, diabetic nephropathy, neuropathy, and or retinopathy. There are certain unusual manifestations like this case that we are presenting. There was an incidental finding of asymptomatic deranged liver enzymes in a pregnant woman who had diabetes and no other cause could be found for the same.
Twenty nine years old woman, married since 12 years, gravida 4 para 2 abortion 1 living 1, presented to the outpatient department at 31 weeks of gestation. Her pregnancy was complicated by preeclampsia; and the first living issue was a was 3 kg male child, born from a full term lower segment cesarean section, who lived well but died at 4 months of age due to pneumonia. Her second child was a female born from a full term normal delivery, 2.5 kg at birth and is now 8 years old. After this she had a spontaneous abortion at 3 months of amenorrhea, followed by a check curettage. There was no history of raised blood sugars in any of the previous pregnancies. Her both parents were diabetic.
In this pregnancy, she had registered elsewhere, and presented at 31 weeks with abnormal fasting blood sugars and was admitted for the same. On examination, she was conscious, oriented, with normal pulse, blood pressure, cardiovascular and respiratory system examinations. On local examination uterus was 30 weeks in size with a live fetus in cephalic presentation and closed cervical os. She had a report of fasting blood sugars measuring 108 mg %. Oral glucose tolerance test was done with 75 gms glucose and the values (all in mg %) were 216 (fasting), 307 (1 hour), 322 mg (2 hour) and 288 (3 hours).
Endocrinologists advised diabetic diet with self monitoring of blood glucose 6 times a day, and injection Human Insulin [R] 10-10-10-0 U and Human Insulin [N] 22-0-0-26 U, subcutaneously was started. She was given injectable steroids for lung maturation (dexamethasone 6 mg 4 doses 12 hours apart) and insulin values were adjusted accordingly.
Incidentally, abnormal liver function tests (LFTs) were detected. Ultrasound abdomen was done which was suggestive of normal liver echotexture with no focal lesions but the gall bladder was distended with sludge. All viral markers of hepatitis and HIV were negative. She gave no history suggestive of any liver disorder such as icterus, itching, nausea, vomiting, oedema, or abnormal bleeding. Upon further questioning, she reported use of some homeopathic medications for 6 months that had been discontinued for the last 2 months. Gastroenterologists opined to avoid hepatotoxic drugs and monitor liver function tests every 3rd day.
However, in view of increasing trends of liver enzymes (as shown in table 1), a decision to terminate pregnancy was taken (at 30weeks 3 days of gestation). Her coagulation profile was checked and was normal. She was taken up for LSCS in view of breech presentation with worsening of liver function tests. She delivered a female child of 1.862 kg, with Apgar score 0f 9/10, was admitted to NICU where she initially required continuous positive airway pressure ventilation and was gradually weaned off. Injection insulin was discontinued on postpartum day 3 and converted to tablet metformin 500 mg 2-1-2 at discharge. Wound check was healthy, daily blood sugars and liver function tests were monitored (as shown in the table 1). She was discharged on day 5 and was asked to follow up in OPD after 15 days for suture removal and her LFT reports. On 19th post operative day when she came to OPD for follow up her LFTs had come to normal. Her recent fasting sugars were 150 mg% and she was taking medications for the same.
Table 1: Pattern of platelet counts, liver function tests and fasting blood sugars from antenatal to postpartum period during her hospital stay
On admission
LSCS
(gm%)
(cmm)
1.15 lakh
1.2 lakh
SGOT
(IU/ml)
SGPT
(mg%)
Liver has a role in maintaining normal glucose homeostasis. In our patient, both liver enzyme derangement and abnormal blood sugar values were detected at approximately the same time. Whether one preceded the other remote from the time of detection is not known. In such a scenario, any of the possibilities could have existed. That is, liver disease as a consequence of diabetes, diabetes as a complication of liver disorder or liver disorder coincidental with diabetes. This association may explain the pathogenesis behind diabetes and abnormal liver enzymes, or it could be purely coincidental.
One study done in 2011 found an association between insulin resistance and aminotransferases, in the absence of detectable steatosis by ultrasonography. This study indicated that in diabetes, even mild steatosis is sufficient to mediate the derangement of aminotransferases.[2]
The presentation of non-alcoholic steatohepatitis can vary from asymptomatic elevated liver enzymes to full blown fibrosis and nodular regeneration. Hence they can be considered as a cause for chronically elevated liver enzymes in asymptomatic diabetic patients, particularly if they are obese and have hyperlipidemia.[3] This could be one of the differential diagnosis in our case. Our patient had BMI of 31.8 kg/m2 but lipid values were not checked.
Ultrasound abdomen showed a normal liver echotexture with no focal lesions and a distended gall bladder with sludge. No specific correlation between pregnancy an non alcoholic steatohepatitis have been reported. Weight loss upto 10%, good control of blood glucose levels and addition of ursodeoxycholic acid can help in normalizing the liver enzymes in such conditions.[4, 5]
Biliary diseases and diabetes have an association, obesity being a common factor. Although in pregnancy, lithogenicity or the cholesterol saturation index of bile increases due to hyperestrogenemia, the biliary sludge that appears in pregnancy is known to resolve post partum and rarely results in gall stones. Our patient had obesity and gall bladder sludge. However, gallstone disease in pregnancy is extremely rare.[6]
Some studies have shown rare association between the use of oral hypoglycemics and liver injury, mostly with use of sulphonylureas, causing chronic hepatitis and necroinflammatory changes.[6] This possibility is less probable in our case as she was diagnosed with diabetes during antenatal visit and was not on oral hypoglycemics earlier. However, this is relevant in patients who may present with diabetes and raised liver enzymes.[7]
Though we cannot comment on the role of homeopathic medications that she had consumed prior to the ANC visit, literature reports a study of toxic hepatitis or drug induced liver injury in Type 2 diabetic patients treated with Gymnema sylvestre. This is a plant which is known to be a potent antidiabetic, widely used in Ayurveda and Homeopathy medications.[8]
A study done by Frazer and associates found an association between chronic hepatitis C and impaired glucose tolerance, and reported that diabetes is found to be more frequent in patients with hepatitis C than in general population.[9] Our patient was negative for viral markers of hepatitis.
Autoimmune hepatitis is another progressive liver disease that can manifest at any time of life, including pregnancy and postpartum. Pregnancy is a period of immune tolerance hence the disease activity of autoimmune conditions attenuates during antenatal period but worsens during postpartum period. Hence post pregnancy is a better time to evaluate presence of autoantibodies.[10] This is not applicable to our study as her LFTs normalized after delivery.
Considering the liver diseases unique to pregnancy, HELLP syndrome which is a complication occurring as a sequel to severe pre eclampsia must be considered here. It is also known that there is a high risk for a diabetic mother to develop chronic or gestational hypertension, specially pre eclampsia. A study by Yanit and colleagues in 2012, reported that pre eclampsia developed three or four times more often in women with overt diabetes.[11]
Another possible explanation for our case could be atypical HELLP syndrome with normal blood pressure in a diabetic pregnant woman. HELLP syndrome comprises of hemolysis, elevated liver enzymes and low platelet count, as a complication in a patient with severe pre eclampsia. Literature study reveals some atypical presentations of this condition where no other etiology could be considered.[12] After delivery the liver enzymes level began to reduce, with improvement in haemoglobin levels and platelet count.
To conclude, diabetes in pregnancy and liver disease could coexist in a patient with various manifestations and possible conditions are discussed above. The condition is discussed because sometimes decisions to terminate pregnancy need to be taken even without a specific diagnosis, and many a time extensive evaluation in postpartum period may be required for accurate diagnosis.
Feig DS, Palda VA. Type 2 diabetes in pregnancy: a growing concern.Lancet. 2002;359(9318):1690-2.
Esteghamati A, Noshad S, Khalilzadeh O, Khalili M, Zandieh A, Nakhjavani M. Insulin resistance is independently associated with liver aminotransferases in diabetic patients without ultrasound signs of nonalcoholic fatty liver disease. Metab Syndr Relat Disord. 2011;9(2):111-7.
Sheth SG, Gordon FD, Chopra S. Nonalcoholic steatohepatitis. Ann Intern Med. 1997; 126(2):137-45.
Palmer M, Schaffner F. Effect of weight reduction on hepatic abnormalities in overweight patients. Gastroenterology. 1990;99(5):1408-13.
Laurin J, Lindor KD, Crippin JS, Gossard A, Gores GJ, Ludwig J, et al. Ursodeoxycholic acid or clofibrate in the treatment of non-alcohol-induced steatohepatitis: a pilot study.Hepatology. 1996;23(6):1464-7.
Kolbeinsson HM, Hardardottir H, Birgisson G, Moller PH. Gallstone disease during pregnancy at Landspitali University Hospital 1990-2010. Laeknabladid. 2016; 102(12):538-542.
Sola D, Rossi L, Schianca GP, Maffioli P, Bigliocca M, Mella R, et al. Sulfonylureas and their use in clinical practice. Arch Med Sci. 2015; 11(4): 840–848.
Shiyovich A, Sztarkier I, Nesher L. Toxic hepatitis induced by Gymnema sylvestre, a natural remedy for type 2 diabetes mellitus. Am J Med Sci 2010;340 (6): 514-7.
Fraser GM, Harman I, Meller N, Niv Y, Porath A. Diabetes mellitus is associated with chronic hepatitis C but not chronic hepatitis B infection. Isr J Med Sci 1996; 32(7):526-30.
Mehta V, Prasad M, Gupta AS. Autoimmune Hepatitis in Pregnancy. JPGO 2016;3(8). Available from: http://www.jpgo.org/2016/08/autoimmune-hepatitis-in-pregnancy.htm
Yanit KE, Snowden JM, Cheng YM, Caughey AB. The impact of chronic hypertension and pregestational diabetes on pregnancy outcomes Am J Obstet Gynecol 2012; 207(4): 333
Garrido MF, Carvajal JA. Normotensive HELLP syndrome: report of one case. Rev Med Chil. 2013; 141(11):1470-4.
Saxena A, Thunga C, Madhva Prasad S, Gupta AS. Deranged Liver Enzymes In A Case Of Diabetes In Pregnancy: Diagnostic Dilemma. JPGO 2017. Volume 4 No.10. Available from: http://www.jpgo.org/2017/10/deranged-liver-enzymes-in-case-of.html
Shetty A*, Madhva Prasad S**, Gupta AS***.
(* Third year Resident, ** Assistant Professor, *** Professor, Department of Obstetrics and Gynecology, Seth GS Medical College and KEM Hospital, Mumbai.)
Developmental anomalies of the Müllerian duct system represent some of the most fascinating disorders that obstetricians and gynecologists encounter. We present to you a case in which lateral approach was used to reach the collection and for excision of a non-communicating functional uterine horn.
Müllerian duct anomalies may produce reproductive failure like abortion and preterm birth, or obstetric problems like malpresentation, retained placenta, or they may be asymptomatic. Uterus with a non-communicating functional horn is a type of Mullerian anomaly and is a rare cause of dysmenorrhea. Here, we present such a case and discuss the management strategies. Reaching and excising such a functional but a noncommunicating uterine horn can be challenging at times but excision is warranted to improve the symptomatology. Chances of occurrence of endometriosis are reduced and future fertility outcomes are likely to improve significantly.
A 14 year old unmarried girl, who had attained menarche a year prior, presented with severe incapacitating dysmenorrhea ever since onset of menses. Cycle length was 28 days with 5 days flow. It was accompanied by severe pain, the height of which was during the menstrual flow. She was evaluated outside and found to have obstructed right functional non-communicating uterine horn and a left functional normal horn and no other medical or surgical illness.
Her general and and detailed systemic examination were within normal limits. Abdomen was soft, non-tender and no masses were felt. Per rectal examination showed midline globular tender right horn of the uterus with what appeared as a distinct palpable depression; across which a left side horn was felt. No adnexa was felt through the right or the left fornix. Impression was obstructed right functional non-communicating horn with left functional normal horn.
Ultrasonography (figure 1) showed uterus anteverted normal size and bicornuate. Left cornual endometrial echo could be traced up to cervical canal with continuity of the lumen. Right cornua was not connected to the cervical canal but it ended bluntly. Organised blood echoes were seen in this endometrial cavity.
MRI showed bicornuate uterus with right non-communicating horn, hyperintense collection in the endometrial cavity (figure 2) with right fallopian tube distended with hyperintense fluid suggestive of a hydrosalpinx. Left horn was normal. She was planned for an exploratory laparotomy with right salpingectomy and excision of right obstructed functional non-communicating horn with metroplasty. Intraoperatively, bilateral ovaries were normal. Left fallopian tube was otherwise normal but had attachment at top of the uterus. There was no uterine fundus above the insertion of the fallopian tubes. Uterine contour was normal on external examination. A faint bulge was seen over the right cornuo-fundal region on careful examination. Upon palpation, a firm globular swelling was felt in the right cornuo-fundal region; with doubtful communication to the cervical canal. However, cervix was single and appeared to be in normal communication with the left hemi-uterus. Right cornual end of the tube had a 1 cm atretic segment with doubtful connectivity to uterine cavity. Hydrosalpinx was present from cornual end just distal to the atretic segment; extending close to fimbrial end but stopping short of fimbrial end with another atretic segment. (figure 3).
Salpingectomy was done carefully ensuring that the ovarian blood supply was not compromised. Needle passed from anterior and posterior surfaces into the presumptive area of hematometra, could not reach the collection. Here, an innovative procedure suggested by Dr. S.V. Parulekar was used. Needle was passed into the hematometra through a lateral approach, between the right round ligament and the right utero-ovarian ligaments. Old collected blood about 2 cc was aspirated out. (figure 4). Diagnosis of hemi-hematometra was confirmed. With the needle as the guide a stab incision was taken and deepened (figure 5) and endometrial cavity was visualized. Lateral part of endometrium showed the tubal ostia, confirming endometrial cavity and tubal attachment. (figure 6). Gentle blunt probing was done and the extent of the horn was assessed in all directions; it was found to be around 2x2x2 centimeter. The endometrium, along with a few millimeter of myometrium was excised using cautery taking care not to excise deep into the tissue (figure 7) so as not to damage the septum between the 2 horns. Cauterization was immediately stopped when the lateral part of the wall of the functioning uterine cavity was identified. Excised tissue was sent for histopathological examination. After ensuring that no redundant endometrium was left in the right horn, small sub-centimeter pieces of gel foam were placed; and myometrial bed was approximated in consecutive layers from below upwards by taking continuous interlocking sutures with polyglactin No 1-0. By this, the functional cavity of the redundant obstructed right horn of the uterus was made non functional and was obliterated. So as to leave behind a single functional cavity of the uterus with communication to the cervix (figure 8). Postoperative course was uneventful and she menstruated subsequently and did not experience any severe excruciating dysmenorrhea..
Figure 1. Sketch drawn by sonologist to depict the pathology.
Figure 2. MRI image with blue arrow pointing to distended uterine horn and red arrow pointing to normal uterine cavity.
Figure 3. Intraoperative findings showing hydrosalpinx and slight right sided uterine bulge.
Figure 4. Laterally inserted needle aspirating blood confirming hematometra.
Figure 5. Proceeding with lateral dissection.
Figure 6. Right sided functional horn excision and coring of endometrium. Blue arrow pointing out to coagulated myometrium, green arrow is pointing out the left horn bulging through the septum between the two horns.
Figure 7. Cavity sutured.
Figure 8. Final view after suturing of serosa.
Surgical procedure designates the correct diagnosis of type of Mullerian anomaly. In our case, the MRI was suggestive of bicornuate uterus with a non-communicating horn. However, intraoperative features, which is the gold standard, showed it to be a septate uterus with a partial septum running from top of the uterus to the right wall, dividing the uterine cavity unequally resulting in non-communication with the cervical canal on the right side. The functional endometrium thus trapped within the smaller cavity caused the severe dysmenorrhea and made her seek medical help soon after menarche.
Terminology and classification of Mullerian anomalies continues to be imperfect, and our patient would probably not fit into any of the classes in the American Fertility Society classification, the VCUAM classification or the Clinical Embryological classification. It would fit into a rather broad U6 (Unclassified Malformations) in the ESHRE classification.[1] The EAC classification is one which may help in correct scientific communication of this malformation, the main advantage being that functionality is also taken into account;[2] and not just the morphological features, as in most other classifications. This patient fits into an unclassified Mullerian anomaly.
When there is no communication between the functional horn and its main functional endometrial cavity or the cervix, symptomatology of severe dysmenorrhea, hematometra and hematosalpinx is expected.[3]
In our case, the symptomatology was seen and hematometra was observed; but hematosalpinx was not observed. This is due to atretic segments of fallopian tube in the cornual end. Probably due to this, she presented at a much earlier time than otherwise expected. Endometriosis was also not seen, though it is expected in patients with non-communicating functional horns with canalized fallopian tubes due to retrograde menstruation.
Many different methods of imaging can be used for confirmation of type of Mullerian abnormality. Ultrasonography is a well-accepted modality; however, 3 dimensional ultrasonography is the best and performs well in comparison to gold standard MRI.[4] As the collection was small we could not reach it anteriorly or from the posterior or superior aspect. However as the myometrium is thinnest in the lateral wall at the cornua the lateral approach worked by a lateral thought process. Though not entirely similar, when other techniques are not feasible, a lateral approach can be considered in surgery of the uterus, as described for myomectomy procedures.[5]
Excision of the horn and coring out of the endometrium was done. Our method also ensured that the resulting lateral wall of the functional horn did not weaken as the majority of the myometrium was retained after coring of the endometrium and closed so as to strengthen the inner septum. As described, this was achieved by open technique. If surgical expertise is available, laparoscopic/ hysteroscopic excision can be considered. But whether the outcomes are better, is not yet clear.[6,7] We present this case so that readers remember this lateral approach when faced with dilemma during surgery and restrict excision to bare minimum.
Dr. S.V. Parulekar, Professor and Head for innovating the unique lateral approach to reach the collection inside the hemiuterus of a septate uterus .
Grimbizis GF, Campo R. Clinical approach for the classification of congenital uterine malformations. Gynecol Surg. 2012; 9(2):119–29.
Parulekar SV. EAC Classification Of Congenital Malformations Of The Female Genital Tract. JPGO 2015;2(4). Available from: http://www.jpgo.org/2015/04/eac-classification-of-congenital.html
Woźniakowska E, Stępniak A, Czuczwar P, Milart P, Paszkowski T. Secondary dysmenorrhea due to a, non-communicating functional uterine horn. Ginekol Pol. 2017;88(7):404–5.
Ergenoglu AM, Sahin Ç, Şimşek D, Akdemir A, Yeniel AÖ, Yerli H et al. Comparison of three-dimensional ultrasound and magnetic resonance imaging diagnosis in surgically proven Müllerian duct anomaly cases. Eur J Obstet Gynecol Reprod Biol. 2016 Feb;197:22-6.
Parulekar SV. Myomectomy: Lateral Extraperitoneal Approach. JPGO 2014; 1(2). Available from: http://www.jpgo.org/2014/02/myomectomy-lateral-extraperitoneal.html
Dwivedi R, Perera K, Eedarapalli P. Non-Communicating inactive rudimentary horn of the uterus presenting with dysmenorrhoea—a case report of successful laparoscopic excision. Open J Obstet Gynecol [Internet]. 2011;1:213–6. Available from: http://www.scirp.org/journal/ojog/
Akdemir A, Ergenoglu AM, Yeniel AÖ, Sendag F, Karadadaş N. Coring-type laparoscopic resection of a cavitated non-communicating horn under hysteroscopic assistance. J Obstet Gynaecol Res. 2014;40(7):1950–4.
Shetty A, Madhva Prasad S, Gupta AS. Lateral Approach To Hemihematometra. JPGO 2017. Volume 4 No.10. Available from: http://www.jpgo.org/2017/10/lateral-approach-to-hemihematometra.html
Laparoscopic Management Of Para-Ovarian Cyst Torsi...
Deranged Liver Enzymes In A Case Of Diabetes In Pr...
Laparoscopic Management Of Non Communicating Rudim...
Successful Management Of H1N1 Infection Complicati...


text:
Final Fantasy: The Spirits Within
Unleash a new reality
"Whoah, there Buzz." you say. "This is Sci-Fi and animated, and I know you love both, but you just gave FF a 4 and The Finger. What gives?"
Well let me tell you kids. This here is genuine SHIT. Let me start with the acting. It's total ass. It's like all the characters in this film are reading lines of dialogue but there is little interaction. As I'm watching the film I can imagine actors in sound recording booths recording their dialogue at 6:00 AM and they're sleepy and don't really care, and none of them are even in the same room together, or the same country for that mater. That's the only "real" feeling I got from this film. Not a single performance is noteworthy. The only thing that is noteworthy is that you got Alec Baldwin, Ving Rhames, Steve Buscemi, Donald Sutherland, and James Woods, and didn't manage to get a good performance. Aside from the voice acting the physical acting is none too good either. It looked like Night of the Living Dead. Facial expressions were stiff at best and body language was weak also. The action poses and movements were pretty good though. Overall though the acting was just horrible.
Next up to bat is the story. GAY! Stupid fucking story. One of the things I hate is when one of the driving characters of a film does things repeatedly that goes against all logic. General Hein who is the main villain of FF doesn't do a god damn thing in this film that makes sense. *** Here is your spoiler warning. *** The General ignores a scientist on what to do about a problem. The General intentionally lowers defense shields, endangering civilian lives, to start a fight. The General shoots the "aliens" with a space cannon and continues to even after it's obvious that this is making the "aliens" stronger. The General is a dick for no other reason than to be a dick. He is a pointless antagonist. In FF the whole earth spirits/Gaia thing kind of sucks. In Princess Mononoke the forest gods are kick ass. You get a big pig with worms coming out of him, and a giant thing with spines on his back that turns into a weird deer thing. Totally creative and cool. In FF we get glowing water. <extreme sarcasm> kick ass. <end of extreme sarcasm> There isn't really anything redeeming about the story.
On the pure animation CGI/FX side things are much better. Some of the scenes were amazing, and the characters when they were still would make you think, "that looks real," then the illusion would quickly disappear. Even though the FX didn't convince me of any kind of realism I still like the style and look of the film. Realism isn't everything. (This film gets it's whole score based upon how the film looks.)
FF as a whole made me feel like I was watching an FX demo that was just going on WAY too long. I felt no attachment to any of the characters, the story, or anything else. It would have been a lot better if I could have watched the best 10 minutes of FF set to techno music or something but since it was 106 minutes instead, (and no techno music) I will have to give it a 4 and The Finger.

redpajama_set_name: RedPajamaCommonCrawl


text:
Q: php: how to assign scraped html to array I want to format what is output by the following php script:
 <?php

$stop = $_POST["stop_number"];  // stop_number is an text input value provided by user
$depart_url = "http://64.28.34.43/hiwire?.a=iNextBusResults&StopId=" . $stop;
$html = file_get_contents($depart_url);
$dom = new DOMDocument();
libxml_use_internal_errors(true);
$dom->loadHTML($html);
$xpath = new DOMXPath($dom);

$my_xpath_query = "//td[@valign='top']";
$result = $xpath->query($my_xpath_query);

foreach($result as $result_object)
{
    echo $result_object->childNodes->item(0)->nodeValue,'
';
}

?>

Here is the output (at least in one instance, as the data changes over time).
18 - GOLD
OUTBOUND
8:17p
8:16p
8 - GREEN
OUTBOUND
8:46p
8:46p
8 - GREEN
OUTBOUND
18 - GOLD
OUTBOUND
5 - PLUM
OUTBOUND

EDIT:
I want the output info above to go in a table such as the one below. However instead of the text between  tags, it would be variables, or items from the php script output.
<!DOCTYPE html>

<title>Departure Table</title>

Next Departures for Stop Number: __

        Route
        Direction
        Scheduled
        Estimated

        18 - Gold
        Outbound
        8:17p
        8:16p

        8 - Green
        Outbound
        8:46p
        8:46p

A: Try appending a \n tag after your echo statement:
    echo $result_object->childNodes->item(0)->nodeValue."\n";

EDIT:
If you want to store your data in PHP variables, you could do something like this:
Store data in an array like variable (or any other data structure as per your needs) and iterate over the variable.
$store_data_in_array_variable = array();

foreach($result as $result_object)
{
    $store_data_in_array_variable[] = $result_object->childNodes->item(0)->nodeValue;

}

//iterate over all stored values

foreach ($store_data_in_array_variable as $key => $value)
{
    echo $key;
    echo '
';
    echo $value;
}

redpajama_set_name: RedPajamaStackExchange


6 Tips for Operating in Hollywood Today and Financing Your Projects.
Alton Glass, CEO of Glassrock Entertainment, is a successful writer-producer-director in a number of genres from Feature films to television. He brought to life the indy comedy, "The Candy Shop," and wrote the prison drama "The Mannsfield 12." His last project the thriller, "The Confidant," features Billy Zane and Richard Roundtree in the cast. His TV series pilot, "The Crew-Los Angeles" was sold to Viacom. Glass was also producer and director for a music show for NBC Nonstop, "Real Music Live." His latest project is a feature-length drama entitled "CRU" about four high shcool friends that experience a tragic car accident and reconnect 20 years later to mend their lives back together. The film features Keith Robinson, Richard T. Jones, Allison Eastwood and Harry J. Lennix to name a few.
Alton Glass, has had an extensive career directing/producing "docu-style" promo's and behind-the-scenes for such artist as Enrique Iglesias, Tony Hawk, Nelly, Florida Georgia Line, Kelly Rowland and more. Utilizing his eye for detail and storytelling, he transitioned this skill into directing and producing narrative feature films and unscripted television. Raised in Detroit, MI, his tenacity and hustle has garnered him Awards such as Best Screenplay at the HBO American Black Film Festival and landed projects with major television networks likes Warner Bro's, MTV, BET, Showtime and others. Recently, Glass has expanded his endeavors with Glassrock Studios—a 3,000 sq ft creative hub for content creation for Film/TV and photography. Glassrock now also offers full production services with a goal to always create results-driven entertainment. Currently, Alton maintains several projects in various stages of production.
Don't miss this talented media artist and filmmaker as he share his experiences, perspectives and advice about our industry today.
EVENT: Industry Perspective: 6 Tips for Operating in Hollywood Today and Financing Your Projects.
NOTE: ADDITIONAL FREE PARKING IS AVAILABLE IN A SPECIAL LOT DIRECTLY ACROSS BRISTOL St. FROM THE DMC.


When taking a dog on a walk, pet owners are faced with an environmental conundrum: What do you do with your dog's poo? Using a plastic bag and throwing it in the trash means covering an organic substance with inorganic material and sending it to the city dump. That seems unnecessarily environmentally destructive. So what to do? Utne Reader's sister publication, Mother Earth News, has some tips on what to do with your pet's dirty business. The article recommends burying the stuff at least 100 feet from any water sources. If that's not possible, dog owners can also invest in some biodegradable doggy bags.
Dude, this was something very informative I come across recently http://www.buygreensavvy.com don't miss to have a look.
I heard about some bags that you can flush in your toilet with the poo. I may try some and try to get off the plastic bag spiral.
I am inundated with extra plastic and paper bags...even bread bags work for this trick: Wear the bag on your hand like a glove. Pick up the poop. Turn the bag inside out...hand never touches the poop. Tie the bag and deposit it in the trash. At home: wash hands just in case.


GotMedia sells a complete line of Thermal Printable DVD-R Media in Orange County, CA. There are 2 things to consider when choosing a thermal printable DVD-R surface. White thermal media is the most popular for most common printing jobs; such as photographic printing. Silver Thermal Printable DVD-R Media offers a metallic background. Most CD DVD Thermal Printers can print on various surfaces including thermal hub printable DVD-R media.
If you would like assistance in choosing the right thermal printable DVD-R Media product for your needs, don't hesitate to call one of our knowledgeable representatives at 1-866-409-1090.


text:
What it's like searching for and starting a new job during COVID-19
Alex Schroeder May 28, 2020
https://www.marketplace.org/2020/05/28/covid-19-job-search-onboarding-open-positions-unemployment/
Amazon has hired more than 175,00 people during the pandemic. What's it like starting a new job there right now? Chip Somodevilla/Getty Images
When it comes to job searching in the middle of the COVID-19 pandemic, Andrea Barringer has seen it all. She interviewed via Zoom for an opening at one company, and in person for another, where the prospective employers weren't wearing masks. She got rejection letters from the retailer Target — three of them, to be exact — despite it being "one of the busiest places" in her area at the moment.
And, most importantly, after six weeks of searching, applying, interviewing and getting rejected, she was finally hired.
According to the Marketplace-Edison Research Poll from late April, nearly a quarter of Americans are not at all confident that they would find a new job within six months if they were to lose their current job. That has more than doubled from 11% in 2019.
And yet, job loss is an intense reality for many people in the U.S. right now, and finding a new source of income is urgent. Roughly 40 million Americans have now filed for jobless aid since the coronavirus forced millions of businesses to close their doors and shrink their workforces.
Those layoffs have forced some people to jump right back into the job market, sometimes outside of their preferred fields. Like Barringer, who lost her job as an office manager for a T-shirt company in Lawton, Oklahoma. She was looking for work everywhere from UPS to dental and CPA offices to a fast food chain.
"My basic background is customer service as a whole, so it was anything that had to deal with customers or working with people is what I was aiming for," the 28-year-old said.
Barringer says many of her applications were met with responses about hiring freezes or already-filled positions. But for those jobs that were still open, she moved on to interviews. In three different interviews, she had three very different experiences.
"The one at the fast food place, no one was wearing a mask, I sat really close to all of them. It was very strange considering the times," Barringer said of her interview for an assistant manager position. "I was confused that they even had an in-person interview."
At the other end of the spectrum, with UPS, she had a phone interview and an interview over Zoom. "It felt pretty natural," Barringer said. "It was a lot of smiling and nodding."
Her third interview, with a veterinary clinic, featured an in-person interview, but at proper social distance, and everyone wore masks. In the end, that's who offered her the job that she accepted. Just one week into the job, Barringer reported being very happy with where she landed.
"It ended up for me, again, very lucky, because that's not the case for everybody," she said.
Trying to make ends meet
For some, the COVID-19 pandemic has meant taking even riskier work after a job loss. As has been widely reported, there's no shortage of jobs in certain retail sectors, as delivery services expand. Walmart has hired more than 235,000 workers. ZipRecruiter says searches for grocery positions have increased 22% since the start of the crisis. CVS said in late March it would hire 50,000 people to keep up with demand.
Taking one of these jobs, however, means taking the health risk that comes with working in a warehouse, store or other densely populated area.
That's been the challenge for Avanne Foster, 31, in Phoenix. She lost her job building hot tubs and spas in part, she says, because she told her employer she would not be coming in over concerns about her asthma during the pandemic. The company maintains that she quit, and has since filled Foster's position.
But she now works even closer to the frontlines, processing and transporting essential goods and food for a logistics company. She found the job on Craigslist.
"I'm still risking my life going in. If I catch it, that's that," she said of the coronavirus.
But Foster has had little choice. She says she's broke, she hasn't gotten a stimulus check yet and she hasn't had any luck with filing for unemployment.
Another major player leading the hiring push is Amazon. It's brought on more than 175,000 new employees during the pandemic. One of them is 26-year-old Stephen Proctor, who left his job as a server at a Texas Roadhouse restaurant near Dallas when it shifted to to-go service only. The pay was no longer sustainable for him at that point, and he found work at an Amazon fulfillment center.
Getting the job was as easy as filling out a virtual "online assessment" and picking a start date, Proctor says — no formal interview. And he estimates he's now making almost triple what he made at the restaurant, as much as $1,500 a week, depending on how many overtime shifts he's able to pick up.
He says the workload was "insane" when he first started because of how much people are shopping online. But the company has tried to retain workers with increased incentives. Since mid-March, Amazon has offered a $2 hourly raise for warehouse workers. The company is phasing that "hazard pay" out at the end of this month. Proctor says he has also gotten paid double his usual rate for overtime shifts.
But there's the question of workplace safety.
"You have a ton of people at the factory, but at the same time, they have huge measures in place to make sure that you're not next to anyone," Proctor said. "They enforce the 6-feet rule like crazy."
He says he feels safer at the Amazon fulfillment center than he would at his old restaurant, which has partially reopened and welcomes new guests through its doors every day.
Onboarding online
Jenna West accepted her new job as a public relations manager for Workhuman, a human resources software company in early February. She was all set to start in the office on March 18.
"On the Friday before I started, I got a call, and [they] said, 'Actually, no. Everybody's working from home, you will be getting your computer mailed to you and everything's going to be remote,'" West said.
It's a particularly hard spot for West to be in because, working in communications, part of her job is getting to know the company and its employees and telling their stories. That's hard to do when she has yet to meet any of her coworkers in person.
"I want to know people, I want to make those connections, I want to hear someone talking in the hallway about something cool they're doing and be like, 'Wait, tell me more about that.' So that's been the hardest thing about being remote, is that I'm not able to build those relationships as strongly as I could if I was in the office" West said.
That said, she's grateful that Workhuman is keeping all of its employees' health and safety in mind by keeping the office closed. And, her onboarding process was smooth: a full week of meetings and facetime with all of her new colleagues. And, for those that were onboarding at the same time she was, they formed a special kind of bond — more pronounced social connection that's crucial in a world still defined by social distancing.
"I understand that those bonds are probably stronger in person, but, at the same time, we had this unique situation that bonded us in a way that not many people can say that they have," West said.
Attention job seekers: "We all have worth, we all have value"
"I like to think that it's traditional art — it's just the Black representation of that"
As COVID-19 lockdown eases, Britain faces an unfamiliar threat: mass unemployment
Is it worth applying for a job right now?
Why are job interviews getting so complicated?
Expect more staycations this summer


text:
Q: XMLHttpRequest fails on IOS with blob and arraybuffer I'm trying to download an mp3 file, about 50kb using XMLHttpRequest (fetch isn't supported on IOS9), it always fails and I can't seem to get any useful error information:
var request = new XMLHttpRequest();
request.open("GET", files_path + '/' + test['test'][i]['sound'].trim() + '?' + token);
request.responseType = "arraybuffer";
request.onreadystatechange = function (e) {
    if (this.readyState === 4) {
        if (this.status === 200)
            console.log('XMLHttpRequest onreadystatechange: ' + this.responseText);
        else
            console.log('XMLHttpRequest onreadystatechange Error: ' + this.status + ', ' + this.statusText);
    }
};
request.onerror = (function(group_test_index, test_index, game_index_, preload, i) {
    return function(e) {
        console.log(new Date().format("dd-MM-yyyy hh:mm:ss") + ' - do_game2() XMLHttpRequest failed: ' + this.statusText);
    }
})(group_test_index, test_index, game_index_, preload, i);
request.onload = (function(group_test_index, test_index, game_index_, preload, i) {
    return function() {
        console.log(new Date().format("dd-MM-yyyy hh:mm:ss") + ' - do_game2() XMLHttpRequest succeeded');

        // https://staxmanade.com/2015/11/how-to-base64-and-save-a-binary-audio-file-to-local-storage-and-play-it-back-in-the-browser/
        var reader = new FileReader();

        reader.addEventListener("loadend", (function (group_test_index, test_index, game_index_, preload, i) {
            return function () {
                console.log(new Date().format("dd-MM-yyyy hh:mm:ss") + ' - do_game2() FileReader loadend');
            }
        })(group_test_index, test_index, game_index_, preload, i));

        reader.addEventListener("error", (function (group_test_index, test_index, game_index_, preload, i) {
            return function () {
                console.log(new Date().format("dd-MM-yyyy hh:mm:ss") + ' - do_game2() FileReader error');
            }
        })(group_test_index, test_index, game_index_, preload, i));

        var b = new Blob([new Uint8Array(this.response)], {type: "audio/mpeg"});

        reader.readAsDataURL(b);
    }
})(group_test_index, test_index, game_index_, preload, i);
request.send();

This prints out Error: 0, '' in Safari console... same problem in Chrome.
Is there a way to get more useful error information, or does anyone have any ideas why this doesn't work on IOS9? (Works fine on desktop)
Thanks!
Simon.


text:
Posted on October 19, 2018 by Record Herald
Hillsboro Indians beat Panthers, 47-13
By Chris Hoppes - choppes@aimmediamidwest.com
Josh Gilmore (9) carries for Miami Trace as he tries to avoid Hillsboro defender Mark Galimore during a Frontier Athletic Conference game at Miami Trace High School Friday, Oct. 19, 2018.
Chris Hoppes | Record-Herald
The Miami Trace Panthers played their final home game of the 2018 season Friday night against the Hillsboro Indians.
It was the final game for Miami Trace with their current high school and stadium.
The Indians got the win over the Panthers, 47-13.
Hillsboro improves to 8-1 overall and is now part of a three-way tie for first place in the Frontier Athletic Conference at 3-1.
Miami Trace falls to 2-7 overall, 0-4 in the conference.
The reason for the three-way tie is that the Washington Blue Lions upended the Chillicothe Cavaliers at Chillicothe, 20-7, handing the Cavs their first conference loss of the season.
Jackson shut out McClain, 55-0 to improve to 3-1 in the FAC.
The Indians started out the scoring with a 62-yard scoring run from Josh Keets.
The extra-point run gave the Indians an 8-0 lead at the 10:09 mark of the first quarter.
Mason Swayne had a long run for Hillsboro that set up the next score, a 1-yard burst across the goal line by Deon Burns.
The point-after kick gave the Indians a 15-0 lead with 6:45 remaining in the first quarter.
Keets then scored on a 61-yard run from scrimmage. The extra point kick was blocked leaving the Indians in front, 21-0 at the 3:43 mark of the first quarter.
Mark Galimore then had a 41-yard touchdown run. the extra point kick was no good, with Hillsboro holding a 27-0 lead.
The Indians scored twice more in the second quarter.
Swayne passed for 10 yards to Luke Middleton with 6:34 to play in the first half. The conversion kick was no good.
The Panthers were knocking on the door of the endzone a bit later in the quarter, but Swayne intercepted a pass in the end zone and ran it out well onto the field of play.
Keets broke a 64-yard run to make it 39-0 with 1:22 to play in the half. The extra point kick was no good.
In the third quarter, Burns scored on a 67-yard run for Hillsboro.
The Panthers got on the board with two touchdowns.
The first was a 9-yard run by Tyler Taylor and the second was a 40-yard run by Josh Liff.
Justin Shoemaker hit one of two extra point attempts to make the final 47-13.
The Indians will host McClain next Friday night and the Panthers will play at Gardner Park against the Blue Lions.
https://www.recordherald.com/wp-content/uploads/sites/27/2018/10/web1_Josh-Gilmore-vs-Hillsboro-.jpgJosh Gilmore (9) carries for Miami Trace as he tries to avoid Hillsboro defender Mark Galimore during a Frontier Athletic Conference game at Miami Trace High School Friday, Oct. 19, 2018. Chris Hoppes | Record-Herald
By Chris Hoppes
choppes@aimmediamidwest.com
Hi! A visitor to our site felt the following article might be of interest to you: Hillsboro Indians beat Panthers, 47-13. Here is a link to that story: https://www.recordherald.com/sports/32269/hillsboro-indians-beat-panthers-47-13


Today we are talking about one of our collaborators, the MAINITIES team.
It seems like yesterday, but it's been more than four years since Laura and Barbara opened their MAINITIES decorating store.
We were lucky enough to start working with them from the very first moment.
Many of you were familiar with our designs such as the SISAUU applique, the NUUS table lamp or the VIMMET stool in his shop in Granollers.
For almost a year now the store has been closed to give way to its interior design projects.
On this occasion the MAINITIES team placed the SISAUU applique in the headboard of the bed.
Our SISAUU applique allows you to adjust its height, whether you want a more focal light, to read for example, or a more ambient light for the whole room, allowing you to have all the space of the bedside table available for your other decorative objects.
The SISAUU wall light is ideal for use in the living room as well.
To illuminate those corners that are more hidden and that with a single touch of light you recover and ample the hall.
En nuestra web https://www.denoedesign.com/product/sisauu/ you will be able to find multiple combinations of colors for your SISAUU, different colors of textile cable to be able to combine it with metallic angle of white or black color or angle of wood.
And you, how do you want your SISAUU application?


Raghu and Sashi took up this journey simultaneously and began to delve into Yoga, Vedanta and Vaastu. Sashi followed the Vaastu stream for over 10 years with Shri Ganapati Sthapati, a renowned exponent of vaastu shilpa shastra, and Raghu followed the Yoga stream for the same number of years with his teacher Shri Krishnamacharya, a renowned yoga expert.
The primary focus of our work has been to unfold the creativity of individuals and groups through offering an appropriate culture for the individuality to grow constantly and, to address the overall health of both the individuals and the system.
How did we evolve this process?
In a recent interaction with some Feng Shui experts, I was asked this question 'why do Indians let go of all their traditions without adequate study?' I was forced to accept this criticism about us – that we do not respect our own past without assurances and encouragement from our colonial masters. Perhaps this is a necessary residue of being a conquered people, or a lacuna in our own psychical makeup. We are very concerned with the polarisation that seems to have emerged between 'tradition' and 'modernity'. We strongly believe that if the best of the tradition should survive the ravages of time, then the quintessence should be judiciously blended with contemporary pushes and pulls.
Our current work is to develop refine and apply the process we call "Vaastu Healing", which implies the holistic integrative understanding of the individual as well as the physical and psychological spaces he / she occupies. Vaastu Healing will be the vehicle for delivering what we refer to as "Dharma through living" – a process of discovering right living & right livelihood.
Vaastu Healing is an institution that facilitates this inner journey. It offers the space where one can visit ones' inner world, and dissolve the life sapping knots. It offers a community space where new and resplendent expressions of the self and deep resonant relatedness can be discovered.
Vaastu Healing has created a space with the intention of reaching out to women, children, youth and couples -the whole extended human family- in such a way that their individual and collective potentials can be released and enriched.
Vaastu Healing comprises of a set of practices that will help the individual harmonise the home and the self, evolve a personal practice that is introspective and engage in work roles with vitality and conviction.
If the negativity and ill health of modernity should be healed, then our contemporary concerns have to stop, and we learn to listen to the wisdom of the land and its ancestors. The middle path is always a difficult one.
We hope to make "Vaastu Healing" both a web university as well as a physical centre where the individual and group can come together to reflect and discover inner and outer unfolding and a convergence between ancient wisdom and contemporary reality. Some theories and philosophies of traditional India have played an important role in shaping the individual and the collective.
In this path of creating newer movements we have recently brought in a group of young people and initiated a centre called Ritambhara (http://www.ritambhara.org.in) . We have also decided to create a physical centre for this experiment. The centre will come up in the Nilgiris in a small village called Konavakkarai around 8.5 kms from Kothagiri. The work has already begun towards this centre. We hope to have 8 double rooms, a training hall, dining and kitchen unit, as well as open air discussion spaces. The land is unspoilt as well as sporting a fantastic view of the forests around this area. Elephants as well as bison and wild pigs are inhabitants of this area. The centre will be ready by end of 2016.
The individual consciousness or Jivatma is connected to the universal consciousness or Paramatma. By sensitising the Jivatma or individual consciousness one understands the meaning of life. Many practices have been recommended for this awakening to take place, such as work, art, devotion and intellectual understanding.
These paths are known as Karma yoga or work, Gnyana yoga or knowledge, Bhakti yoga or devotion.
Who am I? Why am I here? A space to facilitate the person to answer such existential questions.
Every individual has the hidden aspects of innocence, dreams, compassion and love. But the process of living has submerged these feelings. In desperation we ask ourselves the questions that have reverberated over time. "Who am I?", "Why am I here?", "What is the nature of this world?" "What is the purpose of life?" etc. Such questions can only be answered through sadhana.
A mind and a heart energized by absolving itself of these burdens, become capable of insightful, and joyous enquiries into the eternal mysteries of life. One becomes capable of discovering ones' dreams, ones' deep intent, and an ability to live in a manner that remains true to ones' dream and intent.
In our years of work with different groups and people we have found that the average individual is getting more and more fragmented from his / her human family. In the social system, particularly in the larger cities, people are losing touch with their collective identities. The rapid changes and the stress levels prevalent in every day living, further intensifies the loneliness, and fragmentation. Traditional societies offered multiple social institutions which helped to replenish the human psyche / spirit. For example: the Panchayat system where local problems, celebrations, and announcements were handled by the collective and enriched over time through dialogues. But today, when an individual comes home after a hard day's work or study there remains only a neurotic engagement with "TV entertainment" which frequently adds to the stress and prevents genuine dialogues from taking place. We offer a workshop space for like-minded individuals to come together and create an ambience of sharing and collectively inquire about life, relationships, roles, meanings, aspirations, and dreams.
We also run workshops and programmes to facilitate these enquires.


Complete PET for Spanish Speakers offers the most authentic preparation available for the Cambridge ESOL exam. Informed by the Cambridge Learner Corpus, and providing an official PET past exam paper from Cambridge ESOL, Complete PET is the most authentic exam preparation course available. Each unit of the Student's Book covers one part of each PET paper and provides thorough practice for the exam.
Complete PET for Spanish Speakers offers the most authentic preparation available for the Cambridge ESOL exam. Informed by the Cambridge Learner Corpus, and providing an official PET past exam paper from Cambridge ESOL, Complete PET is the most authentic exam preparation course available. Each unit of the Student's Book covers one part of each PET paper and provides thorough practice for the exam. Grammar and vocabulary exercises target areas that cause most problems for PET candidates, based on data taken from real candidate scripts on the Cambridge Learner Corpus. The CD-ROM provides additional exam style practice. The English for Spanish Speakers edition provides specific help for Spanish-speaking students and a PET for Schools practice exam.


Home » English » Europe's New Refugee Problem Requires Explanation beyond War!
Europe's New Refugee Problem Requires Explanation beyond War!
by Bobby Gulshan. The scenes of refugees drowning by the hundreds in the seas between Turkey and Greece as they attempt to reach Europe are harrowing. They come from all corners of the Middle East, not only from Syria, but also Lebanon and Iraq. Lebanon recently received the corpses of a family of eight who died when they illegally took a ship from Turkey heading to Europe. All this while the photo of the Syrian toddler, Aylan Kurdi, remains fresh in the minds of the world.
In growing desperation, some refugees, predominantly Muslims, are converting to Christianity in the hopes that they will be welcomed into new societies. Reports indicate that Iraqi soldiers, wishing to take advantage of the opportunities for new lives in Europe, have also begun deserting their units.
A recent article by Professor Walter Russell Mead in the Wall Street Journal, on September 12, throws light onto perhaps one of the most serious refugee crises Europe has faced since World War II. According to Mead, not only have insecurities and civil wars sent refugees flooding into Europe, but some structural causes, specifically "civilizational" failures both in the greater Middle East and Europe, have fueled the crisis. Ironically, almost 20 years have passed since Samuel Huntington's thesis on the "clash of civilizations" transfixed the world. Now, Mead focuses on "clashes within civilizations," specifically between Arabs and Muslims on one hand, and Europeans and Westerners on the other.
Mead cites the general failure of the Arab world to accommodate modernity as one of the most important civilizational factors contributing to the refugee crisis. He writes, "There is no point in rehearsing the multiple failures since Britain's defeat of the Ottoman Empire liberated the Arabs from hundreds of years of Turkish rule. But it is worth noting that the Arab world has tried a succession of ideologies and forms of government, and that none of them has worked." In fact, Liberal intellectuals in the Arab world have long lamented the failing of various historical movements, whether they be secular, nationalist, or Islamist.
Mead rightly points to the crisis of civilizational identity in Europe and how it contributes to the troubled response greeting the waves of refugees on the continent's shores. As Mead asserts, the contemporary liberalism of Europe wants to "do what is right." However, the compulsion towards what is right confronts real logistical, economic, and political concerns – in short, what is actually possible. A tension exists between pragmatism and the idealism that should be present in the values of Western "Enlightenment." Though it may sound cynical, at the very least, Mead appears a "realist," correctly indicating that while 10,000 refugees on your border may allow you to do what is right and be the Europe of open-armed modern liberalism, but that luxury fades quickly when the number of refugees enters the millions.
According to Mead, a decisive military policy might have quelled the tide of strife sooner, thus reducing long term insecurity, a factor which he identifies as equally significant to poverty in driving mass migration from the Middle East. Some in Europe, including French President Francois Holland, have argued for a more aggressive European military involvement in the region. Yet Mead fails to articulate what this means in practical terms. It's easy to label a policy as "feckless," but much harder to say what that security policy ought to entail. Moreover, it begs the question: shouldn't the almost 100 years of foreign military intervention in the region be considered one of the major factors in the civilizational failures that have resulted in the refugee crisis we see today?


text:
Local 503054211
Permit denied for large hog feedlot in southeastern Minnesota
Owner of site near Mabel, Minn., says the company will take a different tack to keep the 4,890-hog project alive.
By Jeremy Olson Star Tribune
December 18, 2018 — 7:29pm
Minnesota's top environmental regulator has denied a permit for a large swine feedlot in southeastern Minnesota, citing concerns about the region's already-troubled groundwater, though the decision has not quashed the project.
Commissioner John Linc Stine, of the Minnesota Pollution Control Agency (MPCA), said Tuesday he is denying Catalpa Ag's request for a general permit for its 4,890-hog facility. But the company can still obtain a more rigorous individual permit if it takes additional steps to prevent leakage that would contaminate groundwater.
Stine said he made the decision in the interests of the region, which is sensitive to water contamination because its porous, karst geology can allow surface contaminants to reach the groundwater "within a matter of minutes."
"There are thousands of feedlots across the state," Stine said. "This one was in a very sensitive area and did not make sense to me for a general permit."
Catalpa's proposed facility wouldn't be the largest feedlot in the state, but it drew unusual public interest, including hundreds of letters in opposition and two crowded hearings. Concerns ranged from the smell to traffic to the facility's potential to exacerbate or increase the number of sinkholes in the soggy region.
At least one opponent said she was disappointed in Stine's announcement because opponents wanted the agency to order an environmental impact statement (EIS), a comprehensive review that would fully identify risks associated with the project near Mabel, Minn. Under Stine's ruling the site's owner, Al Hein, can apply for an individual permit without conducting such a study, said Dayna Burtness, a hog farmer from Spring Grove, Minn.
"We've been asking for an EIS," she said. "This feels like a dodge."
Most of the state's 1,300 feedlots are covered under general permits, but about 70 have received the more-rigorous individual permits, according to the MPCA.
Reached after Stine's announcement, Hein said Catalpa will pursue an individual permit. Hein, a majority shareholder of the company, argued that the feedlot will offer ecological benefits. Tanks under the proposed barns would collect up to 9 million gallons of liquid manure, which could be used as organic fertilizer on area fields and reduce the amount of commercial fertilizer in the soil, Hein said.
Hein said he was disappointed to be denied the general permit but said it was a victory to not be ordered to conduct a company-funded EIS. Such reviews are common for large-scale projects, such as the proposed PolyMet copper mine in northern Minnesota, but rare for feedlots.
"In that sense, it was a good thing," he said. "If we can just alleviate the other concerns [to prevent leakage into the groundwater] then we just move along with the process."
In lieu of a project-specific EIS, Stine recommended a state-funded study by the Environmental Quality Board of the entire region and its sensitivity to groundwater contamination. Already, 19 of 24 townships in Fillmore County have private wells with nitrate levels above health risk limits, according to a state Department of Agriculture study.
"That fact alone gave me great pause," the commissioner said. "We know the source of nitrates in drinking water comes from our surface activities."
Minnesota Health Commissioner Jan Malcolm praised Stine's decision and supported the call for a regional study, but whether the board will conduct one is unclear. It's also unclear whether such a study would affect ongoing permit applications for Catalpa or other projects.
If Catalpa applies for an individual permit, then environmentalists would once again call for an EIS and everyone would be back where they started, said Bobby King of the Land Stewardship Project, a nonprofit advocacy group that opposes the feedlot.
"There would be only two possible outcomes of an EIS," King predicted. " 'This can't be done safely here,' or, 'This project needs to be substantially changed.' "
Jeremy Olson is a Pulitzer Prize-winning reporter covering health care for the Star Tribune. Trained in investigative and computer-assisted reporting, Olson has covered politics, social services, and family issues.
jeremy.olson@startribune.com stribJO
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text:
Football: Spiro Holds Off Muldrow, 14-12
MULDROW — Spiro's defense turned back a potential game-tying two-point conversion late in the game to hang on for a 14-12 win against Muldrow Friday.
"I feel like we played pretty good defensively at times but there were times where we gave up a big play because we had people out of the right spot," Spiro coach Chris Bunch said. "I give credit to (the defense), but we've still got a lot of learning to do there. We had a lot of blown assignments even on defense which really hurt us.
"We've got to get our minds back right and get those kids to do what we tell them to do because right now, we've got some who's not doing what we're telling them to do."
Spiro (1-1) held a 14-6 lead in the fourth quarter but Muldrow had the ball inside Spiro territory on its first two series in the fourth before turning the ball over both times. McKinley Whitfield intercepted a pass at his own 14 and then Spiro recovered a Muldrow fumble.
But Muldrow (0-2) caught a break after forcing Spiro to punt with less than two minutes left. The snap on the punt was fumbled and Muldrow took over at the Spiro 35.
One play later, Muldrow quarterback Dominic Blue found receiver Wes Durham over the middle for a 35-yard TD with 1:46 left.
Muldrow then tried for the 2-point conversion to tie the game. Spiro's defense rushed Blue out of the pocket and his pass went out of the end zone. Spiro's Cole McKinney then recovered the onside kick and Spiro ran out the clock.
"The turnovers cost us (Friday), I mean one big pick and that was on us, that wasn't on Dominic. … He's only had a week of reps there and he did a pretty good job," Muldrow coach Rob Johnson said. "It's at our fingertips, we just can't get there. We're close, we can feel it but we've just got to get over the hump."
Spiro went up 7-0 less than five minutes into the game when Trevon Mitchem fielded a punt at his own 3, broke a couple of tackles and got loose down the sideline to complete a 97-yard return for a TD. Hunter Wilson added the PAT kick.
Muldrow, which was shut out in its season opener last week against Roland, finally got on the scoreboard for the first time this season when Blue took a keeper and found a gaping hole up the middle from 16 yards out. But the kick was missed, which kept Spiro in front, 7-6.
Late in the first half, Muldrow lined up for a long field goal but faked it. Holder D'Andre Owens tossed it to the kicker, Chris Anderson, who threw a pass to Blue, who was stopped several yards short of the first down.
On Spiro's opening series of the second half, the lead was extended when Whitfield threw a 32-yard TD strike to receiver Malik Walker, who caught it one step ahead of his defender to complete the eight-play, 42-yard series.
"The play was designed to go to me, and I broke them inside then as soon as I came out, I knew I had it," Walker, who also intercepted a pass deep in his own territory in the first half to stop a Muldrow drive, said. "I kind of lost the ball but still made the catch."
Before the game, Muldrow's captains brought a No. 75 jersey in honor of junior lineman Christian Mayberry, who is still in a Tulsa hospital recovering from injuries suffered in a recent ATV accident. Mayberry's number and initials were also painted onto the field.


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11/11/2021	November 11, 2021	 - 1/7/2022	January 7
November 11, 2021 @ 9:00 am - 11:00 am EST Recurring
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The CT Suicide Advisory Board (CTSAB) typically meets the second Thursday monthly from 9-11 AM. Reminders and agendas are emailed via the listserv and are posted to the State Agency Public…
November 11, 2021 @ 12:00 pm - 1:00 pm EST Recurring
The Social Marketing and Communications workgroup implements social marketing and communication strategies to increase knowledge of services across the state, promote stigma reduction, and promote the system of care values,…
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Children's Behavioral Health Advisory Committee (CBHAC)
The Children's Behavioral Health Advisory Committee (CBHAC) was formally established by the Connecticut state legislature through Public Act No. 00-188. CBHAC serves in an advisory capacity on system of care…
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Family Care Connections
The Family Care Connections workgroup designs Family Care Connections that prioritize family and youth voice and choice in the development and implementation of an individualized and coordinated plan of care…
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The Trauma-Informed School Mental Health Task Force works to convene stakeholders across school and community initiatives. Designated meeting time: Fourth Monday of every other month | 9:30 – 11:00 am…
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