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Home » Types of Pain » Spine Pain
10 Articles in Volume 6, Issue #1
Do Topical Herbal Agents Provide Pain Relief?
Infusion Catheter Epidural
New Report of a High-Dose Morphine Metabolite
Pain Education and Pain Educators
Suspecting and Diagnosing Arachnoiditis
Tennant Blood Study — First Update
The Demise of Multidisciplinary Pain Management Clinics?
The Dimensions of Pain
The Role of Psychology in Pain Management
A review of the symptoms noted in a group of patients with arachnoiditis presents an analysis of clinical observations of this disease.
By J. Antonio Aldrete, MD, MS
Arachnoiditis (ARC) is a nonspecific inflammatory process usually caused by an invasion into the dural sac—whether by bacteria, blood, or injections of various irritant substances that produce a spectrum of pathological changes originating on the arachnoid membrane. The resulting inflammatory response eventually proliferates to other intrathecal neural elements leading to fibrosis and adhesions that involve the nerve roots, the arachnoid, the spinal cord, and the dura mater. This progression culminates in permanent disability characterized by severe intractable pain, neurological deficit, and other related symptoms.1 Although this process may involve any site where the arachnoid membrane and neural structures are found, the most common presentation occurs in the lumbosacral region affecting not only the distal spinal cord, but also the cauda equina's nerve root and the sympathetic nerve fibers connected to them.,2 In addition to pain sensory alteration and motor deficits, it may also be accompanied by other symptoms such as low-grade fever, profuse diaphoresis, heat intolerance, nausea, bladder and/or bowel dysfunction, and sexual impairment. Evidently, this syndrome is, by far, more complex than the involvement of the meningeal layers. Whereas the main clinical features represent a physical injury producing functional damage or alteration, the ensuing devastating disease is always associated with unrelenting chronic pain and major psychological and social impacts.
Due to the scarcity of objective data regarding the correct diagnosis of arachnoiditis, the author and a group of collaborators (see acknowledgements) associated with the author's clinical facilities have, over a period sixteen years, tabulated comprehensive data on arachnoiditis patients. The data was obtained from the clinical history from all the medical records available, patient physical and neurological exams, and a review all the available films in 489 patients in whom the diagnosis of arachnoiditis had been suspected or affirmed by other clinicians. All patients were seen personally by the author from 1989 to 2006. A good number of patients were refer to the author's pain management facilities for diagnosis and treatment, with most patients coming from distant states or from other countries. Many other patients came of their own accord after they developed symptoms resembling arachnoiditis following a medically-related event that included incidental invasion of the vertebral canal. In the last decade, by far, the largest number of patients have also received, at one time, the diagnosis of Failed Back Syndrome (FBS). As a matter of clarification, it is important to note that not all the patients having arachnoiditis had FBS and not all the patients with FBS had ARC.
After Charcot and Joffroy3 first described a syndrome resembling ARC in 1869, other series of cases caused by infectious diseases such as tuberculosis,4 syphilis,5 parasitic,6 or fungal organisms7 appeared in the medical literature nearly 150 years ago. In 1909, the british neurosurgeon Victor Horseley8 wrote a classic description of the clinical symptoms, together with operative and postmortem findings in patients with arachnoradiculitis. This classical description was followed by Foix and Alajouanine9 who, in 1926, correlated the symptoms with the location in the spinal cord and nerve root pathological findings. In 1930, Vincent et al.10 described the first non-infective cases of ARC related to the introduction and increased popularity of myelography as a diagnostic test in the 1930's. However, it was not until two decades later11 that the alarm was sounded about the possibility of pantopaque and other oil-soluble contrast media12,13 producing permanent neurological deficit. This feasibility was initially doubted since many of the patients having myelograms either had an ongoing neurological disease14 or had spinal operations15 soon thereafter, so it was therefore difficult to discern the origin of subsequent neurological deterioration or to define the onset of new symptoms. This dilemma was aggravated by the fact that the only diagnostic procedure available to confirm the presence of ARC, at that time, was to perform another myelogram. Even when tomography became available, intradural sac pathology could only be defined when oil-soluble or some of the early water-soluble contrast media were injected intrathecally.16 Although the use of oil-based dyes had been discontinued in Scandinavian countries in 1965, and despite multiple reports of severe arachnoiditis following the intrathecal injection of iophendylate and other oil-soluble dyes, the FDA did not stop its sale in the USA until 1986.
Possible Etiology of Arachnoiditis
Recognizing that arachnoiditis of the lumbosacral spine can also occasionally be caused by infections like meningitis, viruses like HIV, and parasites like echinococcus, readers are referred to a review on that subject.2 This series include a group of patients that apparently acquired this disease while under going diagnostic or therapeutic procedures of the spine. Efforts to identify the possible causative factor(s) were made by reviewing all the pertinent medical records and correlating the radiological findings from the time of appearance of the low back pain. All subsequent procedures and interventions were reviewed. Since many of these patients were not evaluated until months or years after the apparent event that might have caused ARC, a retrospective assessment of the events related to spinal diseases, injuries, operations or any other invasive procedure performed in or near the spine were evaluated to identify any possibly related event in the available documentation. The precise probable cause was identified in 472 cases (96.5%); in the remaining 17 cases (3.5%), probable cause was deduced from sudden changes in the intensity and frequency in symptoms that coincided with a considerable change documented in the neurological exam, together with definite radiological findings reported at about that time. Previously, only a portion of the total number of patients included in this series was published.1 This series encompasses all the patients seen from 1989 to 2006, making this the most current report.
As shown in Table 1, this updated series includes 489 patients (233 men and 256 women ranging from 24 to 94 years old). Most of the patients were middle-aged, with an average of 53.4 years (from 27 to 86 years of age) for men and 48.4 years for women (from 22 to 92 years old). Twenty six cases, in whom some of their medical records and some of their radiographs were reviewed but not examined directly by the author, were excluded from this series.
The type of pain, its frequency, and the location were noted; psychosocial factors such as litigation, Worker's Compensation claims, and work status were also recorded (see Table 2). Similarly, the frequency and type of bladder, rectal, and sexual dysfunction were noted. The occurrence of depression, anxiety and other emotional disturbances were evaluated in separate interviews by a psychologist. The imaging studies were interpreted by an experienced radiologist and by the author.
Table 1. Probable Causative Events In Patients With Arachnoiditis
Myelogram with Pantopaque, (pre 1986) 12 (2.4%)
Myelogram* followed by spinal surgery (post 1986) 16 (3.2%)
One Laminectomy (first) 38 (7.7%)
Laminectomy plus another procedure 18 (3.6%)
Laminectomy, (2nd or multiple) 76 (15.5%)
Spinal fusion with bone graft 36 (7.3%)
Spinal fusion with hardware 71 (14.5%)
Spinal anesthesia 45 (9.2%)
Epidural anesthesia (Lumbar) 51 (10.4%)
Epidural steroid injections (with incidental dural puncture) 53 (10.7%)
Pseudomeningocele following dural tears at laminectomy 27 (5.5%)
Other pain relief related procedure 29 (5.9%)
Thoracic epidural anesthesia (syringomyelia) 5 (1.0%)
Neuroplasty 5 (1.0%)
Vertebroplasty 4 (0.8%)
Spinal "taps" 3 (0.6%)
Total 489 (100%)
*In 1986, the production of oil-soluble contrast media for myelograms was discontinued in the USA.
Possibly Related Disorders
With certain frequency, some non-spinal related signs and symptoms appeared in patients diagnosed with ARC. Readers should be reminded that these statistics do not represent actual incidence of cases of ARC, but simply represent the frequency of each specific possible causative event in the group of patients included this series. Their incidence, as obtained from our group of patients, is shown in Tables 2 to 5. Patients related that these manifestations were not clinically manifested before the causative event which may have produced arachnoiditis, however this fact could not be specifically verified or denied from the review of their medical records.
Other illnesses, present in this group of patients, appeared to suggest the association of some ailments that may have more than a casual coincidence. For example, degenerative disc and/or facet joint disease of the cervical spine was noted in 32 patients (6.5%). Pulmonary disease was also diagnosed in 147 patients (30%)—all of which were, or have been cigarette smokers. Obesity (>20% over the patient's expected body weight) was noted in 129 cases (26.3 %). Spondylolisthesis of the lumbar spine was present in 51 patients (10.4%) and lumbarization of S-1 or sacralization of L-5 vertebrae was reported in 129 (26.3%) and in 19 patients (3.8%), respectively. These abnormalities tend to render the spine unstable at a younger age. Similarly, the presence of short pedicles were noted in 112 patients (22.9%) from radiological studies and is important to consider since the narrower spinal canal appears to magnify symptoms caused by minor lesions. In such a case, a bulging disc, for example, would manifest as severe low back pain with radiculopathy. Another congenital defect is "spina bifida occulta" which again may not manifest with clinical symptoms until a mild injury to the spine results in exaggerated symptoms. See Figure 1 for the telltale presence of a "tuck-in" sacrum in the physical exam.
Table 2. Pain Related And Sensory Symptoms Observed In Patients With Arachnoiditis
Burning pain 478 (97.7%)
Gnawing pain in lumbosacral area 341 (69.9%)
Stabbing pain in lumbosacral area 188 (38.40%)
Constricting pain in legs or ankles 197 (40.2%)
Burning sensation in one foot 239 (48.8%)
Burning sensation in both feet 179 (36.6%)
Segmental numbness in the lower extremities 298 (60.9%)
Tingling sensation in one leg 392 (80.1%)
Tingling sensation in both legs 178 (36.4%)
Hypoesthesia 129 (26.3%)
Formication 66 (13.4%)
Dysesthesia 89 (18.2)
Gait abnormalities 198 (40.4)
Paraplegia 13 (2.6%)
Hyporeflexia in one leg 216 (44.1%)
Hyporeflexia in both legs 84 (17.7%)
Hyperreflexia in one leg 17 (3.4%)
Skin rash 58 (11.8%)
Muscle spasms 447 (91.4%)
Pruritus 49 (10%)
Allodynia 106 (21.6%)
Hyperalgesia 112 (22.9%)
Plantar Neuromas 19 (3.8%)
Table 3. Systemic Symptoms Associated With Arachnoiditis
Low-grade fever of unknown origin 357 (73%)
Frequent headaches (>4/week) 265 (54.1%)
Chronic fatigue 231 (47.2%)
Morning back stiffness 402 (82.2%)
Heat intolerance 416 (85%)
Profuse diaphoresis 409 (83.6%)
Nocturnal diaphoresis 304 (62.1%)
Frequent nausea 42 (8.5%)
Figure 1. "Tucked sacrum" noted in a patient with "spina bifida occulta" .
Dilatation or ectasia of the dural sac was common in those patients that had undergone spinal surgery through the posterior approach. Most of these, 126 ( 25.7%), occurred after laminectomy operations, and 84 others after spinal fusion (17.1%). All 210 of these patients (42.9%) also had clinical and radiological manifestations of ARC. Chronic obstructive lung disease was diagnosed in eight patients (1.6%) while five others (0.9%) had the ominous triad of arachnoiditis, pseudomeningocele, and pseudoarthrosis of the lumbar spine.
Clinical Symptoms in Patients with Arachnoiditis
Severe, unrelenting pain was the predominant symptom in patients with confirmed arachnoiditis. Although presentation had various characteristics, the common denominator was consistently burning pain that was present in 478 patients (97.7%). Low back and unilateral lower extremity pain occurred in 169 patients (34.5%) and 279 (57%) had pain in both lower extremities. The pain radiated upwards to the thoracic spine in 141 patients (28.8%) and 68 patients (13.9%) also had upper extremity pain, but these localizations of pain were possibly unrelated to ARC. The pain-related manifestations, the characteristics of the pain, the sensory and motor deficits, as well as the abnormalities found in the reflexes of the lower extremities are presented in Table 2.
Systemic Symptoms
These patients also presented with a variety of systemic symptoms not specifically related to spinal disease manifestations. Most were related to neurovegetative dysfunction that could, in part, be attributed to the intimate anatomical connection between the lumbosacral spinal cord and the corresponding sympathetic chain. Some of these manifestations have also been described in patients with traumatic spinal cord injuries, multiple sclerosis, and transverse myelitis. Among them are the symptoms listed in Table 3.
Genito-Urinary Dysfunction
Other frequently encountered symptoms were those related to bladder dysfunction, chiefly those affecting the complex sphincter function and having greater prevalence in women (256) with arachnoiditis, therefore they were considered separately from the symptoms that occurred in men (233). Most of these can be encompassed in the so called "neurogenic bladder." To substantiate the origin of the symptoms, volumetric studies were performed by a urologist in order to differentiate them from cases in which pelvic floor weakness had resulted from obstetrical injury or any other cause.
Approximately two-thirds of the patients reported the onset of bladder dysfunction occurring after the injurious event (listed in Table 1). Most of these manifestations are typical of the syndrome referred to as "neurogenic bladder." Sixty one women were forced to do self-catheterization—a rather humiliating self-care procedure—in order to empty their bladder.
Gastrointestinal Symptoms
Bowel dysfunction consisted mostly of constipation in 312 (64%) of the patients and it was usually related to opioid oral intake and was generally treated with laxatives and occasional enemas. Intermittent bouts of diarrhea were noted in 132 patients (26.9%) some of which were also suspected to have irritable bowel syndrome. Severe constipation requiring either colostomy or frequent removal of fecal impaction was noted in 8 patients (1.6%) with either thoracic medullary lesions including syringomyelia (3 cases) or severe injuries to the cauda equina in 26 patients (5.3%). Rectal incontinence, noted in 51 women (19.9%) and 18 men (7.7%), was usually the most disturbing and embarrassing manifestation. Upper gastrointestinal disorders were related to the long-term ingestion of anti-inflammatory medications and occasional steroids. Two patients appeared to have developed fulminant liver failure after long term acetaminophen ingestion (3 to 4 gms daily); in both cases viral hepatitis was also present.
Table 4. Symptoms Related To Bladder Dysfunction In Patients With Arachnoiditis
Symptom Female Male
Dysuria 149 (58.2%) 168 (72.1%)
Hesitation 78 (30.4%) 112 (48%)
Incomplete emptying of bladder 197 (76.9%) 143 (61.3%)
Frequency 225 (87.8%) 136 (58.3%)
Urgency 189 (73.8%) 81 (34.7%)
Incontinence 221* (86.3%) 48 (20.6%)
Needed self- catetherization 61 (23.8%) 9 (3.8%)
*73 of them (28.5%) also had recognized pelvic floor weakness
Only six women (2.3 %) claimed no sexual dysfunction. One hundred and eighteen (46%) had pain at penetration. Two hundred and thirteen (83.2 %) noted loss of libido since the onset of their back pain. Lower back pain during intercourse was reported by 217 (84.6%) women, while 34 of them (13.2%) had pain in their lower extremities as well. 81 patients (31.6%) had exacerbation of their back pain after intercourse. When asked if any particular position for intercourse was better tolerated, 75 patients (29.2%) felt that the sitting on top position was better tolerated, whereas 56 patients (21.8%) preferred the supine position, 57 others (22.2%) were more comfortable on the lateral decubitus with the variant labeled as the "spoon" position, and 3 others (1.1%) felt it was less uncomfortable when sitting on a bench or sofa.
Symptoms and incidence of sexual dysfunction in the male patients are presented in Table 5. It is evident that impotence was the most common dysfunction; however no adjustments were made for the usual sexual dysfunction that may be present in a normally-aging population. The group of patients (233) is considered too small to conclude any significant result, especially since there was such a wide range of ages.
Table 5. Manifestations of Sexual Dysfunction In Male Patients With Arachnoiditis
Reduced libido 198 (84.9%)
Partial and short lasting erection 96 (41.2%)
Complete impotence 113 (48.9%)
Perineal pain during erection 29 (12.4%)
Perineal burning during erection 16 6.8%)
Low back pain during intercourse 135 (57.9%)
Lower extremity pain during intercourse 8 (3.4%)
Low back pain after intercourse 154 (66%)
Received counseling 29 (12.4%)
Unsuccessful counseling 21 (72.4%)
There is no doubt that chronic back pain affects sexual activity. Although many of the patients in this series had low back pain before the apparent onset of arachnoiditis, no effort was made to differentiate it from the effect of chronic back pain, alone, on sexual performance. However, it was evident that sphincter and perineal muscle-related manifestations were more apparent after the symptoms of ARC became evident. While most of these symptoms were enough to have affected their sexual performance, it was impossible to discern what additional impact anxiety and fear of pain might have had on arousal and performance during intercourse. It was also not determined how sexual dysfunction was affected by pain during coitus and how it may have affected these patients' sex lives. While the sexual component has been generally ignored in the past, the impact on adult patients' quality of life and interrelationships requires that it be recognized and addressed. Physicians that care for this patient population need to regularly document the type of symptoms and psychological responses as they relate to sexual function.
Before the appearance of symptoms attributed to ARC, 87 of the male patients (37.3%) played some sport or performed regular physical exercise. Similarly, 112 (43.7% ) women played some sport regularly. In all cases, regular physical exercise was interrupted after the injurious event. All patients reported that they had to abandon most outdoor leisure activities because exerting themselves usually exacerbated the intensity of the pain.
Habits and Circumstances
Certain habits and social conditions were present with sufficient regularity to establish a pattern which merits notice. For example, 469 patients (95.9%) complained of insomnia while 361 patients (73.8%) required hypnotics for treatment. Dreams were reported in only 132 patients (26.9%). In addition, 336 patients (68.7%), of which 182 were males and 125 females, smoked cigarettes, but only 18 patients (3.6%) admitted to drinking alcoholic beverages in excess. Total disability had been granted to 394 (80.5%) while 19 patients (3.8) were partially disabled. Only 29 of them (5.9%) worked full time and an undetermined number of them had some part time work. When first seen, 112 patients (22.9%) were involved in litigation and 22 others (4.4%) had settled previous claims.
Radiological Diagnosis
In every case, the clinical diagnosis was confirmed by diagnostic imaging studies including either magnetic resonance (MRI) or a myelogram followed by a computerized axial tomography (CAT) scan, when the former was contraindicated. It is suggested that if one or more of the following lesions is present in a patient, then a diagnosis of arachnoiditis is confirmed.
intrathecal calcification
enhanced nerve roots (see Figure 2)
clumping of nerve roots (see Figure 3)
adherence of nerve roots to the wall of the dural sac (see Figure 4)
abnormal distribution of nerve roots within the dural sac
extradural scarring in continuity with a deformed dural sac
Intrathecal pseudocysts
Abnormal pattern of dye distribution within the dural sac pseudomeningocele (see Figure 5)
intradural scarring
dural sac deformity or narrowing
residual oil-soluble contrast media in the dural sac
multiple deposits of contrast media with irregular distribution (see Figure 6)
Extrapolation of Radiological Findings
Using plain films, only the recognition of an intradural calcification or a residual droplet of oil-soluble dyes (pantopaque) can suggest the presence of ARC. The wide acceptance of surface-coil magnetic resonance imaging (MRI) as a non-invasive diagnostic test—without danger of further re-injury—has made it possible to arrive at a more precise diagnosis, especially when thin slices are used. The axial and sagittal views allow the identification of nerve roots and dural sac pathology displaying, in detail, the type of abnormal findings as described by Ross et al,17 Delamarter et al,18 and others.19,20 Limitation of the usefulness of MRI has been encountered in patients with metal devices in the proximity of the spine or near delicate organs such as the eyes or the brain. In these instances, a myelogram followed by a lumbar spinal CAT scan is indicated.21
Figure 2. Axial view of the MRI of the lumbar spine demonstrating "Enhanced (edematous) nerve roots (black arrows). Figure 3. CAT scan of the lumbar spine demonstrating all nerve roots in a single clump (arrow head). Figure 4. Four axial views of an MRI of the lumbar spine showing in the two upper frames, the normal location of the nerve roots in the posterior half of the dural sac, situated at the L3 vertebra. In the two lower frames, clumped and asymmetrically located nerve roots are seen at L4. (small arrow head). Nerve roots are also adhered to the dural sac on the right, lower frame (large arrow head). Figure 5. Pseudomeningocele (P) posterior to the dural (S) sac at the level of L5, after an L5-S1 discectomy. Figure 6. Distribution of multiple small droplets of pantopaque at different level, from L3 to the end of the dural sac at S2. Figure 7. Axial view of an MRI of a normal lumbar spine showing most of the nerve roots symetrically located in the posterior half of the dural sac. Two nerve roots are ascending toward the anterior corners of the sac in their way toward departing through the lateral foramen.
Other radiological findings, such as when the conus medullaris and nerve roots are either deviated or tethered by adhesions or trapped or compressed by intrathecal scar tissue (identified in an MRI or a CAT scan following myelography22,23), suggest that an adhesive arachnoiditic proliferative process is already going on three months after the injurious event. In either of these imaging studies, the absolute confirmation is obtained when the nerve roots are clumped and asymmetrically located in comparing one side to the other. This abnormal distribution is in contrast to their normal appearance of being symmetrically located on both sides with the roots individually identifiable (see Figure 7). Nevertheless, in the first three months after the injurious event, "enhancement," meaning edema of the nerve roots, may be visualized by intravenously administering the contrast media gadopentate dimeglumine to patients.24 In myelography, images of the dural sac appearing as having being "painted with a brush with little paint," blunting of axillary root pouches, dural cuff cysts, pachymeningitis, and abrupt obliteration of the dural sac are all suggestive of ARC.21
Not uncommonly, the type, location and distribution of symptoms in patients suffering from ARC are atypical because they superimpose the signs and symptoms produced by other underlying disease such as recurrent herniated discs, spinal stenosis, spondylolisthesis, facet arthropathy, meningitis etc.25 This confusion makes the precise clinical diagnosis of arachnoiditis and each of the accompanying spinal conditions difficult and requires a meticulous and careful radiological interpretation. 17,18,21 From the author's experience, a certain pattern of clinical manifestations were found and documented in every patient seen (see Tables 2 to 5). While such symptoms pointed toward the clinical suspicion of ARC, a case was not considered confirmed unless there was also an unquestionable and objective radiological diagnoses.
Myeloscopy
Other authors have claimed that arachnoiditis can be diagnosed by direct visualization with a myeloscope.26,27 This assertion is questionable at best since the field of vision with this device is very limited. At worse, the invasion of the dural sac does not warrant the information obtained since the arachnoid will undoubtedly be perforated and thus initiate a "flair-up" process if ARC is already present. In addition to having poor documentation from the photographed sites, the extent and location (multiple levels) cannot be determined convincingly. The likelihood that the endoscopist would initiate treatment (lysis of adhesions) in lesions that could not be confirmed by others, have cast a doubt of suspicion over this procedure. Moreover, since it has been shown that those adhesions will form again—and the procedure, itself, may stimulate further noxious stimuli that will exacerbate the clinical syndrome—this diagnostic and therapeutic modality is not recommended.
Attempts to apply electrodiagnostic tests, including EMG, nerve conductions studies, and evoked potentials—commonly used to diagnose peripheral neuromuscular diseases28,29—have not rendered a consistent pattern that could be identified as that of arachnoiditis. Nevertheless, they have been useful in confirming the presence of other concomitant illnesses such as radiculopathy, diabetic neuropathy, etc. or to rule out neurological disease such as multiple sclerosis, amyotrophic lateral sclerosis, and others. Aside from these benefits, a definite electrodiagnostic pattern has not been found that would make any of these tests pathognomonic of arachnoiditis.
Current Epidemiology
As Table 1 shows, most cases of lumbar arachnoiditis represented in this series were most likely caused by therapeutic interventions such as laminectomies,30,31 fusions,32 epidural anesthesia,33 spinal anesthesia,34 epidural injections of steroids,35 neuroplasty or adhesiolysis,36 neurolytic agents,29 some local anesthetics in high concentration,38 epidural blood patches39,40 and, less commonly, other invasive diagnostic procedures such as traumatic myelograms with water-soluble dyes,41 discographies, lumbar punctures, and any other invasion of the vertebral canal. These cases may, in fact, be due not to the procedure itself but most likely to the accidental injury of the dura, with injection of an irritant chemical substance (methylene blue, acrylate, etc), blood into the intrathecal space, or even single traumatic spinal taps.
In order to reach the subarachnoid compartment, insertion of a needle that penetrates the dura undoubtedly has also to perforate the arachnoid membrane. It follows that intradural lesions can occur even after the slightest of trauma to the spinal cord or nerve roots (paraesthesiae) thereby initiating an inflammatory reaction in this trabecular membrane, followed by the appearance of some features common to ARC.42 These include some cases of syringomyelia subsequent to a traumatic puncture of the spinal cord43,44 or when pseudomeningoceles45 appear after spinal operations. Cases of multiple invasive interventions with injections of chemically irritant substances such as depo-medrol46 and methrotraxate,47 by repeatedly producing inflammatory responses of the arachnoid and the adjacent dural wall, may eventually result in arachnoiditis ossificans,48 arachnoid cysts,49 or pachymeningitis,50 all of which are extreme features of ARC .
In addition, cases of cauda equina syndrome and transient nerve root irritation that are usually thought to be only functional, temporary complications, are shown—through non-invasive diagnostic tests (coronal views in MRI images, nerve conduction studies and EMG)—to be quite the opposite by identifying definite lesions within the cauda equina. In the author's opinion, for most of these cases, the inflammatory phase51,52 behaves, clinically and functionally, as ARC and eventually progresses to permanent neurological deficits.53
Interpretation of Symptoms
Although the presence of signs and symptoms that do not conform with the representation of typical radiculopathy may cast some skepticism about the patient's veracity and credibility, physicians must realize that, in arachnoiditis, there are desynchronized reflex responses to random production of hyperesthesia that result in axonal injury.54 Burning sensations which appeared in over 90% of our patients with arachnoiditis (see Table 2) are usually evoked by sustained pressure during nociceptor sensitization (noticed after long standing or walking), but always outlast the period of stimulation. These pain signals are most likely transmitted by fast-conducting primary afferents, as when severe burning pain is seen after repetitive stimulation or ectopic firing.55 On the other hand, sensory deficit manifestations such as tingling, "pins and needles," formication, and even pruritus seen in some of our patients (see Table 2) may represent ectopically-generated nerve impulses to certain maneuvers such as stretching or flexing the lower extremities, turning from the supine to the lateral position, both of which induce excitation of deep tissue afferents.56,57
Hyperesthesia (see Table 2) appearing weeks after surgery may herald Wallerian degeneration accompanied by an increase of endoneurial fluid pressure58,59 extending to the distal root ganglia which, in turn, generates a mechanical stimulus to evoke abnormal activity in sensory neurons.60 Another mechanism, occurring 4 to 6 months after laminectomy, may have a role in the production of areas of hyperesthesia alternating with areas of sensory diminution. This mechanism involves considerable constrictive scarring and fibrosis surrounding a nerve root (extradurally) and thus compromising the intraneural blood flow sufficiently enough to result in localized ischemia.
Further, traumatic lesions of the nerve roots or the spinal cord by either traumatic punctures, spinal fractures, forceful surgical retraction,61 or dissection, etc., may eventually affect some portions of the Lissauer's tract and the substancia gelatinosa which are thought to participate in some of the mechanisms of pain suppression.62,63 This finding suggests that at least some of the deafferentation type of pain may be due to an indirect dis-inhibition of the dorsal horn's transmission cells. In these instances the pain-related symptoms will be evident in the immediate postoperative period.
Another mechanism for the production of ARC is the accumulation that may occur outside of the dural sac after surgical operations. Though is recognized that the blood, itself, does not usually cross the dural barrier, substances such as leukotrienes and cytokins resulting from the degradation of blood cells may do so.64
A recently identified source of discomfort, previously ignored, is the presence in post-lumbar spine laminectomy patients in whom fibrosis and scar tissue proliferates at the site of the operation constricting the dural sac and dilating it distally.65 This complication appears three to six months following surgery and results in a gradual enlargement of the diameter of the sac, accompanied by markedly altered circulation of the cerebrospinal fluid from brain-to-spine and vice versa. Moreover, the function of the arachnoid villi, that allow unidirectional exit of the CSF toward the venous circulation is markedly reduced, if not obliterated, by this proliferative process. This condition manifests as a continuous gnawing and uncomfortable sensation of pressure in the lumbosacral spine and is usually not relieved by anti-inflammatory or narcotic analgesics.
Mechanical irritation (walking, pedaling, and gardening) may be associated with an erithematous discoloration (rubor) and a warming sensation of the feet that appears to initiate, by stimulation, a sympathetic mediated pain (see Table 2). The occurrence of antidromic vasodilatation, as well as mechanical and thermal hyperalgesia may be interpreted as a recruitment of the sympathetic nervous system into reflex action contributing, by default, to an unorganized vasomotor symptomatology. This would explain the complex mechanism of the neuropathic pain phenomenon experienced by patients with ARC that includes sympathetic-mediated symptoms and signs.66
The feasibility of having different mechanisms for different types of pain appears plausible, as allodynia, hyperalgesia, and burning sensations are subtypes of neuropathic pain.60 This sympathetic-parasympathetic imbalance may be responsible for the frequent diaphoresis, heat intolerance, and nocturnal hyperactivity of the sweat glands seen in ARC. This also suggests participation of an autoimmune reaction, as some patients appear to be more susceptible to develop more scarring and adhesions in the healing process than others (see Table 3). This variant is perhaps an exaggerated response generated by an antigen-antibody reaction in a hypersensitive patient.66 These neurotoxic responses may repeatedly generate endogenous pirogens resulting in an intermittent low-grade fever, similar to that seen in patients with lupus erythematosus, polyarteritis nodosa, Reiter's syndrome, etc. Though, there is no specific pattern, low-grade fever implies an active autoimmune process67 with its usual periodicity and is a concept supported by the findings of abnormal activity of gamma-glutamyl transferase in CSF,68 defective fibronolysis,69 and in some cases of arachnoiditis and failed back surgery syndrome.
As shown in Table 2, pain is a common denominator in every case, but to better understand this pain (usually derived from either a direct or an indirect injury to the intraspinal nervous system), it may be recognized that it is not uncommon that this neuropathic pain is also accompanied by some sensory loss phenomenon1,25 as occurs with needle-produced paraesthesia. In brief, this painful dysesthesia,42 caused by either isolated or repeated nerve root trauma, such as when the clumped nerve roots rub against each other or when pain is elicited as the patients extend their legs or flex their spine, and in so doing, essentially stretch the nerve roots. Portions of the these nerve roots—which are normally free floating in the CSF—are fixed as they adhere to each other or to the wall of the dural sac thus eliciting what amounts to ectopic nerve impulse activity with single or multiple burst charges.55 This mechanism has some similarity to the paraesthesia provoked by stretching or tapping on a nerve trunk and somewhat similar to the perceptions that cause allodynia and/or hyperalgesia, indicating an increased mechanosensitivity.56,57
Contrary to the pain seen in a classic radiculopathy—that usually projects along a nerve trunk or follows a nerve dermatome and of which the most typical is sciatica—pain in patients with ARC does not extend along a continuous path, but is present in regions or patches either at the medial upper section of the thigh, or at the posterolateral aspect of the distal thigh or may appear irregularly on the lateral distant portion of the leg. When it does extend to the toes, it is accompanied by fasciculations in the early stages and by frank muscle spasms later on.58,59 This unusual mapping may represent irritation of nociceptor afferent fibers transmitted to muscle fibers in the form of desynchronized reflex responses to random ectopic firing.55 In some cases, certain plasticity has been shown when pharmacological manipulations have been performed on recovering fibers, axons or neurons after a variety of injuries.70,71 In some instances, segmental numbness may be due to the predominant effect of descending impulses upon the dorsal horn, supposedly followed by the projection of neurons of the spinothalamic tract and possibly connecting with inhibitory interneurons located next to the dorsal root ganglion entry's zone. This may control the extent of the sensory deficit manifested on the skin distribution.72 If followed in detail, some of these representations can be traced back to the location, the side, and the level where the clumping of the nerve roots is present.
The extent and severity of sexual dysfunction are alarming as reported by many patients that experienced pain during and after intercourse, which resulted in overt fear and hesitation for sexual activity, mainly because most physicians do not inquire about them and do not document this important aspect of the patient's disease. The prevalent symptoms were different among the genders; in the males, partial (60%) or total (40%) impotence was the most common and feared; loss of libido and difficulty in arousing where also common. In some cases, if erection was obtained, pain and burning sensation would occur at ejaculation. Sexual dysfunction in the female group consisted mostly of loss of libido and severe pain (pelvic, lumbar or in the lower extremities) during or after intercourse, resulting in worries and concern for their lack of active participation in marital sex. Frequently, in both groups, low back and/or lower extremity pain during or after intercourse was stoically tolerated by patients in an effort to please their partners (see Table 3).
Moreover, the partners' desire not uncommonly was tempered by the concern for causing pain and injury to the patient. Needless to say, this scenario lead to disappointment and friction that were prelude to intermarriage conflict. Though advice on trying different positions was at times helpful, counseling with the patient and or his/her partner did little to improve their actual sexual performance although it did help them to understand it and accept it as part of the disease. Since sexual dysfunction was a major contributor to the loss of self-esteem, depression, and relative isolation seen in many of these cases, physicians are encouraged to ask patients about it, document it in their records, follow it, and refer patients to sex therapists when deemed necessary.
Smoking cigarettes is considered a prevailing factor in postoperative morbidity73 since it contributes to respiratory complications,74 delays healing, and probably increases the incidence of pseudoarthrosis and pseudomeningoceles45 from frequent coughing and resultant increase in intradural pressure. This appears to be an ominous habit; in order to have the optimal chances of success, practitioners most insist that smoking cessation is achieved, especially if spinal surgical intervention is contemplated.75,76 Of interest was the finding that excessive alcoholic beverage ingestion was reported in patients in whom the prescription of analgesics and other adjuvant medications had been considered inadequate and inappropriate.
Urinary hesitation and dysuria were found more frequently in males, however, this symptom is not unusual in middle-aged men with early benign prostatic hypertrophy. It emphasizes the need for a complete work-up in order to arrive at a precise diagnosis. In women, urinary incontinence was the most frequent sign of bladder dysfunction. Urinary retention was commonly seen as one of the alarming signs of cauda equina involvement in the immediate postoperative period. Bladder dysfunction included a variety of symptoms that may or may not be included within the label of "neurogenic bladder." These may include "dripping or leaking" as a result of a dysfunctional sphincter. Incomplete emptying produces persistent residual urine which may become easily infected. A combination of storage and emptying dysfunction is secondary to sympathetic receptors malfunction and afferent nerve dysfunction having a myriad of symptoms such as frequency, urgency, incontinence, and hesitancy. The symptoms were noted to be more frequent and more severe in females than in males for patients having ARC after spinal surgical interventions.
This review of the symptoms noted in a group of patients with ARC—with or without failed back syndrome—represents an analysis of the author's clinical observations of these diseases. The author's interpretations are aimed to inform those who care for these patients that the intensity, frequency, and characteristics of these manifestations are real. In brief, this article has attempted to identify the possible path of transmission and perception, while recognizing that much is still in the unknown category.
Since most cases of arachnoiditis and the so called failed back surgery syndrome are caused during a diagnostic or therapeutic intervention of the spine, there is a certain reticence to admit that, in most instances, it is a disease related to interventionism gone astray.77 It raises the question as to whether diagnostic (myelograms, spinal taps, discograms, etc.) or therapeutic invasions of the spine (laminectomies, fusions, epidural or spinal anesthesia, neuroplasties, epidural injections of steroids, etc.) need to be limited to specific indications.
The majority of patients in this series were not working, required assisted care, made frequent doctor visits, underwent repeated procedures that only produced temporary pain relief and, even though most of them were taking a myriad of medications, including opiates, they continued to experience severe pain. Considering that the severity and chronicity of such morbidity includes life-term suffering, psychological dysfunction, and physical disability—resulting in an enormous cost to the health care system—prevention in this case, by far outweighs the effectiveness of any therapeutic modality attempted.
In caring for these patients, one cannot help but to emphasize that it is primordial to make thoughtful and objective decisions regarding interventional diagnostic or therapeutic modalities of the spine, given the potential for an adverse long-term outcome. Since, at present, there is no definitive cure for this condition, emphasis needs to be placed on prevention. Invasive interventions in the spine should only be performed when absolutely necessary and only when such procedures have been shown to offer a definite benefit to the patient.
The author wishes to acknowledge the valuable assistance of Rhamsis F. Ghaly, MD; Thomas L. Brown, MD; John Brannan, MD; Luis A. Vascello, MD; Juan Zapata, MD; Brent Decker, PhD; Valentina T. Aldrete, DDS, MHSA, JD; Sonya Johnson, RN; Frederika Montpetit, PL; Kay Williams, RN; Lou Decker, PRT; and Olga Suarez, MD in caring for these patients and gathering the data presented in this article.
1. Aldrete JA. Clinical Diagnosis. In: Arachnoiditis: the silent epidemic, JA Aldrete (ed.) Futuremed. Denver. 2000. pp 201-220.
2. Aldrete JA. Infections. In Arachnoiditis: the silent epidemic; J A Aldrete (ed). Furturemed. Denver. 2000. pp 41-48.
3. Charcot JM and Joffroy A. Deux cas d'atrophie musculaire progressive avec lesions de la substance grise et des faiseeaux anterolateraux de la mo¢lle espiniere. Arch Physiologie. 1869. 2:354.
4. Krause F. Zur kenntnis der ruckenmarkslashmungen. Verh Kongr Inn Med Pt. 1907. 1:108-113
5. Schwarz E. Syphilitisehe myelomeningitis Mit Holenbildung in Ruchenmarke and Besodneren Dcgenerativen Veranderum Gen Der Neurologia. Wien Klin Wochenschr. 1897. 10:177. .
6. Madrazo I, Sandoval M, and Gonzalez D. Evaluation of the thalamic hypophyseal axis in patients with hypertensive hydrocephalus due to neurocysticereosis. Investigation Med. 1991. 2:113-119.
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21. Boden SD, Davis DO, Dina TS, et al. Contrast enhanced MR imaging performed after successful lumbar disc surgery. Prospective study. Radiology 1992. 182:59-64.
22. Mangar D, Gonzalez W, and Linden C. Gadolinium-enhanced MRI and autopsy findings in a patient with cauda equine syndrome. Anesthesiology. 1993. 78:785-787.
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24. Vroomen PC, Wilmink JT, and de Krom MC. Prognostic value of MRI findings in sciatica. Neuroradiology. 2002. 44:59-63.
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26. Blomberg R. A method for epiduroscopy and spinaloscopy: Presentation of preliminary results. Acta Anaesth Scand. 1985. 29:113-116.
27.Shimoji K, Fujioka H, Onodera M, et al. Observation of spinal canal and cisternae with the newly developed small-diameter, flexible fiberscopes. Anesthesiology. 1991. 75:341-344.
28. Katims JJ. Electrodiagnostic functional sensory evaluation with pain: A review of the neuroselective current perception threshold. Pain Digest. 1998. 219-230.
29. Magda P, Latov NBrannagan TH III, et al. Comparison of electrodiagnostic abnormalities and criterioa in a cohort of patients with chronic inflammatory demyelinating polyneuropathy. Arch Neurol. 2003. 60:1755-1759.
30. Matsui H, Tsuji H, Kanamori M, et al: Laminectomy induced arachnoiradiculitis: a postoperative serial MRI study. Neuroradiology. 1995. 37:660-666
31.Carrage EJ. The surgical treatment of disc degeneration: is the race not to the swift? Spine J. 2005. 5:587-588.
32. Deyo RA, Nachefson A, and Mirza SK. Spinal fusion surgery- the case for restraint. N Eng J Med. 2004. 350:722-726.
33. Reynolds F. Damage to the conus medullaris following spinal anesthesia. Anaesthesia. 2001. 56:235-247.
34. Poulakka R, Haasio J, Pitkanen M, et al. Technical aspects and postoperative sequelae of spinal and epidural; anesthesia; A prospective study of 3230 orthopedic patients. Reg Anesth Pain Med. 2000. 25:488-497.
35. Wilkinsonb HA. Dangers from methylprednisolone acetate therapy by intraspinal injection. Arch Neurol. 1989. 46: 721-725.
36. Aldrete JA, Zapata JC, and Ghaly R. Araclmoiditis following epidural adhesiolysis with hypertonic saline: Report of two cases. Pain Digest. 1996. 6: 368-370
37. Katz JA, Schchorst S, and Blisdard KS. Histopathologic changes in primate spinal cord after single and repeated epidural phenol administration. Reg. Anesth. 1995. 20: 283-290.
38. Kitagawa N, Oda M, and Totoki T. Possible mechanisms of irreversible nerve injury caused by local anesthetics. Anesthesiology. 2004. 100:962-967.
39. Aldrete JA and Brown T. Intrathecal hematoma and arachnoiditis after prophylactic blood patch through a catheter. Anesth & Analg. 1997. 84:233-234.
40. Diaz JH. Permanent paraparesis and cauda equine syndrome after epidural blood patch for post-dural puncture headache. Anesthesiology. 2002. 96:1515-1517.
41. Howland W J and Curry JL.: Experimental studies of Pantopaque arachnoiditis. Radiology. 1966. 87: 253-257.
42. Aldrete JA. Neurologic deficit and arachnoiditis from neuraxial anesthesia. Acta Anaesthesiol Scand. 2003. 47:3-12.
43. Bromage PR and Bernumoff JL. Paraplegia following intracord injection during attempted epidural anesthesia under general anesthesia. Reg Anesth Pain Med. 1998. 23:104-107.
44. Aldrete JA and Ferrari H. Myelopathy with syringomyelia following thoracic anaesthesia. Anaesth Intensiv Care. 2004. 32:100-103.
45 Aldrete JA and Ghaly RF. Postlamineetomy pseudomeningocele: an unsuspected cause of low back pain. Reg. Anesth. 1995. 20: 75-79.
46. Nelson DA. Intraspinal therapy using methylprednisolone aetrate: 23 years of clinical controversy. Spine. 1993. 18:278-282.
47. Weitz EM. Paraplegia following chymopapaine injection: A case report. J Bone Joint Surg Am. 1984. 66:1131-1135.
48- Ng P, LorentzI, and Soo YS. Arachnoiditis ossificant of the cauda equine demonstrated on computed tomography scanogram. A case report. Spine. 1996. 21:2504-2507.
49. Roeder MB, Hazan C, and Jinkins JR. Ruptures spinal dermoid cyst with chemical arachnoiditis and disseminated intracranial liquid droplets. Neuroradiology. 1994. 37:146-147.
50. Barker LF and Ford FR. Chronic arachnoiditis obliterating the spinal subarachnoid space. JAMA. 1937. 109:785-786.
51. Avidan A, Gomori M, and Davidson E: Nerve root inflammation demonstrated by magnetic resonance imaging in a patient with transient neurologic symptoms after intrathecal injection of lidocaine. Anesthesiology 2002. 97:257-258.
52. Aldrete JA. Nerve root irritation or inflammation diagnosed by magnetic resonance imaging. Anesthesiology. 2003. 98:1294.
53. Lauretti GR. Pain transmission and modulation. In: Arachnoiditis: the silent epidemic..IA Aldrete (ed.), Denver Futuremed. 2000. pp 19-37.
54. Thelander V, Fagerland M, Friberg S, et al. Straight tests versus touch and pain afferents in single fascicles of the human ulnar nerve. Brain. 1990. 113: 1491-1500.
55. Nordin M, Nystrom B, Wallin U, and Habarth KE. Ectopic sensory discharges and paraesthesia in patients with disorders of peripheral nerves dorsal roots and dorsal columns. Pain. 1984. 20:231-245.
56. Ochoa JL. The newly recognized painful ABC syndrome Thermographie aspects. Thermology. 1986a. 2: 65-73; 308-316
57. Ochoa JL, Comstock WJ, Marohettini P, and Nizamuddin G. Intrafascicular nerve stimulation elicits regional skin warming that matches the projected field of evoked pain. Shaible, Vahle-Hinz (ed). Fine Afferent Nerve Fibers and Pain. Verlagsegesellschaft, Weinheim, 1987b. pp 476-479.
58. Powell HC, Myers RR, Costello ML, et al. Endoneurial fluid pressure in Wallerian degeneration. Ann Neurol. 1979. 5:550-557.
59. Myers P,R, Rydevick BL, Heckman HM, et al. Proximo-distal gradient in endoneurial fluid pressure. Exp Neurol. 1988. 102:368-370.
60. Howe JF, Loesscr JD, and Calvin WH. Mechanosensitivity of dorsal ganglia and chronically injured axons: A basis for the radicular pain of nerve root compression. Pain. 1977. 3:35-41.
61. Myers RR, Yamamoto T, Yaksh TL, et al: The role of focal nerve ischemia and Wallerian degeneration in peripheral nerve injury Produciong hyperesthesia. Anesthesiology. 1993. 73:308-316.
62. Rocha-Lauretti G. Pain Transmission and modulation. In Arachnoiditis: the silent epidemic. J.A. Aldrete (ed). Futuremed. Denver. 2000. pp 19-37.
63. Wall PD. The role of substancia gelatinosa as a gate control. In Bonia JJ (ed.) Pain. Raven Press. New York. 1980. pp 205-231.
64. Cassin B, Naidoo S, Ramsaroop R, et al. Immunolocalization of bradykinin receptors in human tissue. Inmuinopharmacology. 1997. 36:121-125.
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66. Couto da Silva JM, Couto da Silva JM Jr, Aldrete JA. Body temperature and diaphoresis disturbances in a patient with arachnnoiditis. Anesth Analg. 2001. 93:1578-1579.
68. Akimov GA, Komahdenko NI, and Zinchenko VA. Activity of gamma-glutamyl transferase in the eerebrospinal fluid of various forms of cerebral arachnoiditis. Zh Nevropatol Psikiatr Im S S Korsakova. 1995. 86:682-684.
69. Cooper RG, Mitchell WS, lllingworth KJ, et al. The role of epidural fibrosis and defective fibrinolysis in the persistence of postlaminectomy back pain. 1991. 16:1044-1048.
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Last updated on: April 13, 2017
Referred Back Pain


I have no idea where April Fool's Day originated from, or why it's on April 1 for that matter. And to be honest, I'm not much of a prankster.
However, last year I decided to go all out for April Fool's Day and boy, was it worth it. Let's just say I'm really glad I had the camera on me so I could record these priceless moments.
Here's a picture gallery with a couple of ideas from last year to get your creative juices flowing for the big day tomorrow. I laugh every time I see these pictures and I hope they bring a smile to your face too.
#2 (No Picture for this one) Pin their underwear together.
A new trick I'm going to add to my repertoire is to make homemade jello and pour it in a drinking cup. I'll then stick a straw in it and let it gel. I cannot WAIT to see them try to drink their "juice" tomorrow.
This is one of the things I love about Motherhood. Creating memories with our children that will weave their hearts together with ours. The things we do for or with our children don't have to be outrageous or expensive. They just want YOU to have fun with them.
Have any more kid-friendly ideas for April Fool's Day? There's still time for me to put some more together so let me know your ideas in the comment section below. Thanks!


I am one of the very privileged original members of Liberty Trust and was pleased to be able to not only pay the necessary 'contributions' for myself, but was also able to give contributions on behalf of each of my five children, who were each later able to continue the payments themselves.
It wasn't long before I myself received an interest-free Loan from Liberty Trust and Ark Resources which has been a tremendous blessing and benefit for me, allowing me to continue paying for my home in Opotiki, without any added interest, over a number of years. I expect to have my home paid off within the next 2-3 years.
This has also been very beneficial to me during my eight years here in China, where I am a student of the Chinese language, and also have had many opportunities to assist local students with opportunities to practice their oral English, which they have needed both for their higher level exams here and for opportunities to study abroad. I also endeavour to assist poorer people in a variety of ways, including locating good used clothing for them. My Chinese language has not progressed as well as expected, but one Chinese Professor commented "Your English is getting better & better" !!
who have assisted in remarkable and valuable ways in making this valuable organisation achieve so effectively.


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text:
Vol 34 No 3 /
Explosive Forming of Low Carbon Steel Sheet into a Stepped Disc Shape
S. Balasubramanian Defence Metallurgical Research Laboratory, Hyderabad
S. Sarvat Ali Defence Metallurgical Research Laboratory, Hyderabad
E.S. Bhagiradha Rao Defence Metallurgical Research Laboratory, Hyderabad
DOI: https://doi.org/10.14429/dsj.34.7686
Keywords: Explosive Forming, Stepped Disc Shape
This paper deals with the explosive forming of deep drawing quality steel into a two stepped disc type shape. An attempt has been made to predict the forming parameters from theoretical considerations by equating the disc shape with an equivalent dome. Results of forming this shape in a single stage vis-a-vis forming in two stages are compared.
Balasubramanian, S., Ali, S., & Rao, E. (2014). Explosive Forming of Low Carbon Steel Sheet into a Stepped Disc Shape. Defence Science Journal, 34(3), 235-256. https://doi.org/10.14429/dsj.34.7686
Copyright (c) 2016 Defence Science Journal
where otherwise noted, the Articles on this site are licensed under Creative Commons License: CC Attribution-Noncommercial-No Derivative Works 2.5 India

redpajama_set_name: RedPajamaCommonCrawl


text:
Northwestern offers a vibrant piano program with opportunities for performance, tours, paid accompaniment, and ministry. Choose from five majors in music or a music minor.
Majors for Piano Students
Piano students may choose from a variety of tracks for their course of study. These include Music Performance, B.A. Music, Music Education, Music Composition, and B.S. in Music with an Emphasis in Music Ministry.
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Entrance auditions are required for all students wishing to pursue a degree in music. Auditions are held during spring semester. Students must be admitted to both Northwestern and the Department of Music & Theatre in order to major in music. Please refer to Music Auditions & Scholarships for audition requirements and dates.
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Piano Institute at Northwestern is designed to help students ages 10–18 take their piano playing abilities to the next level. Students are challenged and encouraged in their piano studies while enjoying the friendship of other students who share a similar passion for music.
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The Northwestern Piano Solo Festival is open to all piano students in grades 4–12, with awards given in three categories: grades 4–6, 7–9, and 10–12. Piano Solo Festival is an adjudicated performance designed to encourage young students, both as church and classical musicians, to further develop their God-given musical gifts. All participants will receive a scholarship voucher applicable to UNW's Summer Piano Institute. Donations to the Piano Scholarship Fund are always gratefully accepted. Make checks payable to University of Northwestern (UNW). You may contact Dr. Lange, festival director, with questions about the Piano Solo Festival at (651) 631-5242 or RALange@unwsp.edu.
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Top piano students go on a tour each fall semester, providing opportunities to perform piano duets, solos, and concerto movements (with piano accompaniment) for schools, churches, and community centers.
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I saw The Pixies and Jellyfish at the Academy Theatre.
The Pixies were organically gutted out of the earth during the early grunge movement. When I say that, I say it with sincere respect and love of their creativity. Translating music into an almost surreal slap in the face brought devoted fans to listen to their music, go to their performances and buy their CDs.
I saw them play a show right before their first break up in 1993 at the Academy in New York City. This was even before I studied their lyrics or read about their music background and philosophy.
Superficial things I liked: They had a girl bass player and backup singer, Kim Deal, with perfect, understated delivery. Their lead singer Black Francis (Charles Thompson IV) had all his nerve endings exposed on stage. He held back nothing. The drummer (Dave Lovering) was a tightly run time clock with endless energy. The band rounded itself out with startling, edgy Joey Santiago on lead guitar.
More significant things I liked: The music from this Boston-based band was and is well crafted, angular, tittering from quiet trance to violent screaming. The words are influenced by surrealism and arranged between Kim's tuneful backup vocals to Black Francis's Holy Ghost explosions.
In the 80's, record companies created their own fabricated stars. Youth music was losing its street creds and disillusioned teens and young adults needed music that spoke for them. The late 80's early 90's brought a welcome break from over-produced highly polished pop music.
Their breakthrough album Doolittle for me and many others was a benchmark in alternative rock music. My era was the mid 80's, rock had gotten tired and soggy. Doolittle had so many songs with power and uncontrollable artistic pulse. It WOKE US UP! I still listen to it regularly on my iPhone.
Not only is this music collection critically acclaimed and put at number 227 in Rolling Stone's all time top 500 greatest albums, it is a permanent fixture on my listening devices.
An example song in Doolittle is called Debaser. The definition of Debaser in this song means to break with standards of morality and what is considered 'art'. The imagery compressed into the words and music is inspired by the Salvador Dali short film Un Chien Andalou (1929), in which a calm woman is filmed having her eyeball sliced. In this album, the Id is exposed, Sexuality, guilt, mental illness and disgust are not off topic. Other songs include studies on toxic waste, despair and unrequited love.
With all this seriousness, they do have an ability to view themselves with a sly, sardonic humour. They are not a contrived product of the record industry. That's why it works. That's why a person like me, a positive glass-half-full type of person can still relate to and enjoy their music. Because it's real.
Let's put it this way, the Pixies inspired Kurt Cobain of Nirvana, a band that was also an eruption out of youth angst.
The Pixies are currently touring and released a new single in 2013.
This book is a great overview of the Pixies. It has detailed song interpretations and an interview with Charles Thompson (Black Francis).
Their new 2013 single and video - Bagboy.
What's better than going to a rock concert? Going to a rock concert with your sister and mom!
It may not sound 'hip' but when my mom and sister visited me in the spring of 1993 in New York City, I got tickets for a concert at the Academy on 43rd Street. The band we saw was the Jellyfish.This power pop band was actually new to me. I was playing drums in a band called The Peaces and my bandmates raved about them and said I simply must go. The little amount of music I heard sounded great. Apparently, they put on a good show, they dressed colorful in a rave-like style, and I thought my mom wouldn't get too blown out of her seat (fingers crossed). I don't have pictures of the concert but I was so proud to have my mom and sister share this musical experience with me. I only saw them once or twice a year so it was a real treat.
Here is my band during this time. This version of The Peaces comprised of two sets of brothers and myself! I was only with them for about a year but it was fun. I hadn't pulled this photo out in years, yikes, forgot I was a blonde then. You know what they say: Old rock musicians never die, they just stay under the illusion they never get old, lol.
So off to the concert we went. Since I was with family, my other band members got their own tickets and sat separately.
Jellyfish is a band originating from San Francisco. The main members and songwriters were Andy Sturmer, lead singer and drummer, and Roger Manning, keyboards and guitar.
They specialized in strong in-your-face power pop with creative instrumentation. They were expert at creating music 'hooks.' Along with others, I would compare them to Queen, the Beach Boys and the Beatles. They were influenced by many great bands before them and they didn't try to hide it. A lot of their music choices were very obviously a Beatle's lick or a Queen's harmony. Their sound was intense and saturated. Kind of like your ballerina music box on steroids.
The concert was smoking, the most striking thing was the lead singer in the front playing drums STANDING UP! He balanced on the left foot and playing the bass drum with the right. They were able to pull off their studio sound live. My mom and sister really enjoyed the evening together with lots of screaming fans.
Bellybutton - Spilt Milk is great too.
I cannot believe they didn't make it any bigger than they did. Dripping with well written lyrics with just enough satire to be cheeky. They teetered on the edge of being over-produced, but the sound they got is still wonderful to listen to.
The Academy Theatre 234 West 43rd Street New York City (Not to be confused with the Academy of Music on 14 Street). The Academy was a great venue. It carried a certain air of intimacy, being an old classic concert theater. Many acts performed there including The Rolling Stones. There were at least a couple tiers of balconies and it felt like you were going to a theater that showed ballets but instead, it was rock and roll!
@fullofshoes: Thank you so much for stopping by!
Great review, thank you. Featured on squidoo.com/the-pixies-doolittle-not-shocked under MUSIC.
@TransplantedSoul: I miss going out to see shows. I'm out in the country now and am too lazy to drive to Richmond or D.C. Thank you for stopping by. I'm hoping to get more of a discussion here eventually.
I love idie music. In fact I am going to a local concert tonight of two excellent local musicians.


I'd like to virtualize a miriad of external networks that we have to connect to.
Ideally, I'd like to have a /16 virtual network, that depending on the IP range, would be NATed to a different destination network.
For the purpose of the example above, my LAN network is 10.60.0.0/16, the virtual network would be 10.181.0.0/16, while the real NATed destination would be 192.168.0.0/16. I could connect to a virtual IP of 10.181.1.100 and be NATed to 192.168.1.100.
I thought to use NAT 1:1 configuration + virtual IPs, but I cannot achieve the target configuration with OPNsense.
So far, the documentation lets me think that I could use NAT 1:1 for this purpose, even if usually it's used to allow public IPs to be accessible in LAN.
What am I missing? Is it achievable with OPNsense?


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The Bros aren't the only ones excited about prose. See what others have to say about their work.
"To have the opportunity to watch [Bros do Prose] perform is to sit in on a master class years in the making – but accessible to all ages."
Anna Holbrook
Emmy Award Winning Actor and Educator
"It's absolutely incredible! It's truly for ALL ages
-- don't miss it"
Christopher Tate
"My 2nd grade students told me it was the best show they had ever seen!"
Elementary Teacher, CT
"The Adventures of Robin Hood" energized and inspired our entire student body! Every element of the production exceeded our expectations; from the professional staging, lighting and sound to the dynamic actors who truly engaged all students. The kids were buzzing about exciting storytelling and hopeful for more theatrical experiences to come to our school! Thank you!"
Luke Forshaw
Principal, Ox Ridge Elementary School
Darien, Connecticut
"With all the precision, agility and endless stamina possible, these two terrific actors bring to their enthusiasm to the stage, which spills out over the footlights and encourages audience involvement."
- Chicago Theatre Review
"Robin Hood is a wonderfully enticing show. It captures the imaginations of both children and adults with its quick humor and witty choreography. The physical adaptation of this timeless story is very entertaining to watch. Audiences of all ages will be so impressed that 2 amazing actors take on the role of so many familiar characters. Their talent in telling the story keeps the audiences engaged and in the end.....important life lessons are always learned. Not to be missed!!"
Diana Ryan


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Eagleby
Wondering what to do in Eagleby?
Discover Eagleby's best activities, free events and tickets. Find what's on today, this weekend or all year. Search for everything from yoga to festivals, from gigs to sports, from stuff for kids to adults-only. All the best events are here.
Events in Eagleby
Fri 3rd Mar 2023, 6:00 pm - 10:00 pm AEST
70th Anniversary of the Rotary Club of Beenleigh
20 Alamein St, Beenleigh QLD 4207, Australia
Wed 15th Feb 2023, 6:00 pm - 9:00 pm AEST
Combined Services Dinner
28a Alamein St, Beenleigh QLD 4207, Australia
Wed 8th Mar 2023, 6:30 am - 8:30 am AEST
Soroptimist International Beenleigh - International Women's Day Breakfast 2023
Thu 22nd Jun 2023, 9:00 am - 2:00 pm AEST
Fri 3rd Mar 2023, 9:00 am - 4:00 pm AEST
The Ultimate Sales Mastery Workshop For Small Business 1-DAY Intensive
Kent St & Crete St, Beenleigh QLD 4207, Australia
Fri 2nd Jun 2023, 9:00 am - 4:00 pm AEST
Fri 6th Oct 2023, 9:00 am - 4:00 pm AEST
Thu 9th Feb 2023, 6:00 pm - 7:00 pm AEST
Zen Yoga Qigong class with Michael Bromley
10-12 Atlantic Drive
Thu 16th Feb 2023, 6:00 pm - 7:00 pm AEST
Thu 23rd Feb 2023, 6:00 pm - 7:00 pm AEST
Thu 2nd Mar 2023, 6:00 pm - 7:00 pm AEST
Thu 9th Mar 2023, 6:00 pm - 7:00 pm AEST
Thu 16th Mar 2023, 6:00 pm - 7:00 pm AEST
Thu 23rd Mar 2023, 6:00 pm - 7:00 pm AEST
Thu 6th Apr 2023, 6:00 pm - 7:00 pm AEST


Today we are teaching about death to hate and resurrecting of love. This is something we need now more than ever. The Bible says "to love your neighbor as you love yourself" (Matthew 12:31). If we start to live that way, the world would be a much better place.
Today is TEACHABLE TUESDAY!! Stay tuned for what we'll be teaching you today!!
Ha rá lépsz erre a padra...le teszed a munka gondjait...és nem gondolsz a jövőre! Nem akarsz tervezni....nevelni...példát mutatni...irányítani!
#AntCannStepstyle . Get you some Brasstracks NOW.
My boy @chefenglishcooks put me onto to this group and I spent the whole day listening to their catalog on @spotify until I got to this track. This was on repeat. I decided to make this video. I had a lot of fun with this one.
So here is one minute of it. I did the whole song though... .
🎶 @brasstracks - Officially Missing You cover 🎶 .
#thankyou for creating this art.
#grateful to those who support me.
Type to me tell me what you think... Do you want to see the rest?
Tech notes: I did way more compression. So I could normalize closer to 0 dB. I'm going to buy a #compressor probably in pedal form.
A snippet of our set last night...We were excited to create some choreo to a remix of @thereallilbri 's song Run It Up for her 18th bday bash! Go follow her and peep all her music- when I say she can spit bars for dayzzzz I mean it!!! A female rap artist from right here in #Htown we were honored to be able to show luv the best way we know how- through dance!!
Thank you for having us! 😎 .
It's been a week already since our #SPEAKSummit2019 ! Here are a few highlights. For full videos, follow us on @youtube .
Stomp Factory is excited to be performing for the one and only @thereallilbri at her BDAY BASH! 🎂.
This event is open to the public! E2 Ultra Lounge!!
Today is SOULFUL SUNDAY!! Stay tuned to see what we're feeding into our soul today!!
These cru members have been together for a minute and it shows anytime they get to perform together! #crewlove #squad .


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I've Found One Common Trait in Every Interesting Person's Story: They Love to Read
by Kara Goldin
There is no fool-proof, well-defined road map for charting out a successful career or building a thriving business. Or being an interesting person. It's not a one-size-fits-all proposition. But I'll let you in on one secret that's true of every leader and entrepreneur that I've admired and emulated throughout the years: they're all voracious readers.
People are usually shocked to learn that I read about a book a week (plus several articles a day) — all while running my company, raising my four kids (plus two dogs), authoring a book and staying committed to living healthily. Reading has always been a priority for me because it's yet another way I feed my insatiable curiosity. It allows me to understand how different people think and how they approach the world. Reading lets me get in the heads of some of the most brilliant thinkers and business people out there, folks I may never get to actually talk to face-to-face but who I get to learn from through the life lessons they've committed to paper.
So, naturally, I wrote my own book, Undaunted: Overcoming Doubts and Doubters, because everyone's journey is unique, and I wanted to share how I found success on my own terms by overcoming the obstacles in my path. In this way, I'm repaying the debts I owe to authors who have helped me along the way and created the foundation for a philosophy that I call Undaunted Leadership.
Who are those influential authors and business leaders? Let's start with these three…
1. Simon Sinek's Infinite Game taught me to think bigger than my business.
Here's the gist: most business owners approach success all wrong. Too many people think about running a business as a finite contest — like a game of football or a round of chess — where there's a clear end point, everyone's playing by the same rules, and one side wins after everyone else loses. In reality, business is an infinite game, where everyone's playing by different rules (and you can even make up your own rules!), there can be multiple winners, and the goal isn't to reach a successful endpoint but to keep on succeeding day after day.
Infinite Game was nothing short of a total mindset shift for me — a powerful lesson in how I approached my business, especially in a world where I'm surrounded by Silicon Valley unicorns seeking out growth and "winning" at all costs.
If I had approached Hint as a finite game, honestly, our path would have focused on quarterly sales metrics above all else, expanding as quickly as possible — even if that meant compromising our product or our values — and ultimately cashing out with a big exit and calling it a day. Certainly, many people may have seen that as a successful outcome, but that's never what I had in mind for Hint. Simon Sinek offered me a different way to think about my business, and it became essential advice for me.
By approaching our company as an infinite game, we've been able to make a meaningful impact so far beyond producing delicious unsweetened flavored water. It allowed us to launch new product lines completely outside of the "category," knowing we were fulfilling on our mission to give customers healthier options. It's allowed us to support initiatives that make the world a better place, like pushing for clean water legislation and tirelessly working to make our supply chain more sustainable. It's helped me attract and inspire the most talented people because they know they are getting behind something important. And, on top of all of that, it's allowed me to build a brand that I'm proud to stand behind every single day.
2. Scott Galloway's The Algebra of Happiness taught me the kind of resilience that carries me forward.
As may be evident from the title, this book literally breaks down the equations for creating happiness and success. It has informed so many of the fundamental ways I live my life, and more than anything it has had a profound influence on how I view failure.
Specifically, Scott takes us through the equation that success = resilience / failure. In other words, succeeding is not a matter of never having failed. In fact, we know the opposite is true — failures are inevitable. Instead, it's a matter of how much resilience you have to get through the tough times. Failures set you up to see obstacles as something you overcome rather than insurmountable barriers.
Hint would have fizzled out in the very early days if I wasn't prepared to confront failure. We spent years trying to figure out how to increase the shelf life of the product so we could ship it around the country, without adding preservatives or other unnatural chemicals. Each time we thought we cracked the code, we found a flaw in the logic. So we continued to sell Hint locally and build our loyal hometown customers, and we continued to learn about our brand and our fanbase — while figuring out how to overcome that shelf-life issue. It was the passion of those early Hint fans that gave us the confidence and the resilience we needed to keep at it and eventually perfect the formula that would get us over the hump. In a lot of ways, failure was the ingredient that helped us ultimately succeed.
Side note: I often think about Scott when I head out on my morning hikes because of this little gem: "the ratio of time you spend sweating to watching others sweat is a forward-looking indicator of your success."
3. Bill Campbell's Trillion Dollar Coach taught me to focus on the people around me.
I often wish I could have been mentored by Bill Campbell, the leadership coach and business executive behind many of Silicon Valley's most successful companies (including Google and Apple). Instead, I got to read this book, written by three executives who worked closely with him, which dives into the principles he used to build higher-performing teams and leaders.
Yes, I learned so many tactical lessons from this book that helped me improve my own leadership. But, more than that, it reminded me of the importance of people in building a successful business.
I've always thought of myself as a "people person," starting from my first job working a cash register to waitressing through college and chatting up my customers. But this book is a reminder of how critical the people around me are in the success of my business. Making the investment in showing up more intentionally for those relationships is an essential part of my job. It takes constant work and dedication to your team to be a good leader. This book makes one thing clear: I will never "make it" and that task can never be crossed off a list. Instead, I am constantly learning and figuring out what works for me and my team — adjusting as we grow and iterating as our needs evolve. Bill's advice taught me that showing up and really being there for my team could help us get through nearly any challenge.
These are just three examples amongst dozens and dozens of books that have helped me get unstuck or forced me to reevaluate my old assumptions. My advice to you is to always have a great book on hand and carve out the time for a good read.
And if you need that extra push, go ahead and download one of these phone backgrounds that writer Austin Kleon created.
What Does It Take to be a "Best-Led" Company?
Negotiation. It Might Not Be What You Think.
Going Against the Grain. And Why It's Often Necessary.
Risk, Reward or Both?
Get Going and Disrupt Already
Starting a Company – and Why Not Having ALL The Answers Is Better
Get Kara's Insights In Your Inbox


text:
Drogo (Dreux lub Drogon) (ur. 17 czerwca 801, zm. 8 grudnia 855) – nieślubny syn Karola Wielkiego i jego konkubiny Reginy.

Po śmierci ojca, jako kandydat do tronu i zagrożenie dla Ludwika Pobożnego, został przeznaczony do kariery duchownej. W 818 roku został klerykiem, a w 820 roku opatem w Luxeuil. Od 823 roku był biskupem Metz.

Przez całe życie pozostaje wierny swojemu bratu Ludwikowi Pobożnemu. Po śmierci Ludwika Pobożnego służył wiernie jego najstarszemu synowi, Lotarowi.

Został pochowany w kościele opactwa św. Arnulfa w Metz.

Karolingowie
Urodzeni w 801
Zmarli w 855

redpajama_set_name: RedPajamaWikipedia


text:
Myanmar envoy appeals to U.N. to stop coup; more protests planned
(Reuters) – Myanmar's U.N. envoy urged the United Nations to use "any means necessary" to stop a military coup there, making a surprise appeal on behalf of the ousted government as police cracked down on anti-junta protesters.
The Southeast Asian country has been in crisis since the army seized power on Feb. 1 and detained elected leader Aung San Suu Kyi and much of her party leadership, alleging fraud in a November election her party had won.
The coup has brought hundreds of thousands of protesters to Myanmar's streets and drawn condemnation from Western countries, with some imposing limited sanctions.
More protests were planned for Saturday, activists said, and police were out in force in parts of the main city of Yangon.
Myanmar's ambassador Kyaw Moe Tun told the U.N. General Assembly he was speaking on behalf of Suu Kyi's government and appealed to the body "to use any means necessary to take action against the Myanmar military and to provide safety and security for the people".
"We need further strongest possible action from the international community to immediately end the military coup, to stop oppressing the innocent people … and to restore the democracy," he told the 193-member U.N. General Assembly, receiving applause as he finished.
Kyaw Moe Tun appeared emotional as he read the statement on behalf of a group of elected politicians that he said represented the legitimate government.
Delivering his final words in Burmese, the career diplomat, raised the three-finger salute of pro-democracy protesters and announced "our cause will prevail".
Reuters was not immediately able to contact the army for comment.
Opponents of the coup hailed Kyaw Moe Tun as a hero and flooded social media with messages of thanks.
"The people will win and the power-obsessed junta will fall," one protest leader, Ei Thinzar Maung, wrote on Facebook.
U.N. special envoy on Myanmar Christine Schraner Burgener pushed the United Nations for a collective "clear signal in support of democracy" and told the General Assembly no country should recognise or legitimise the junta.
China's envoy did not criticize the coup and said the situation was Myanmar's "internal affairs", saying it supported diplomacy by Southeast Asian countries which protesters fear could give credibility to the ruling generals.
Singapore said violence against unarmed civilians was inexcusable.
Uncertainty grew over Suu Kyi's whereabouts on Friday, as the independent Myanmar Now website quoted officials of her National League for Democracy (NLD) party as saying she had been moved this week from house arrest to an undisclosed location.
One lawyer acting for her, Khin Maung Zaw, told Reuters he had heard the same from NLD officials but could not confirm it. Authorities did not respond to a request for comment.
The lawyer said he had been given no access to Suu Kyi ahead of her next hearing on Monday, adding: "I'm concerned that there will be a loss of rights to access to justice and access to legal counsel".
Protesters have taken to the streets daily for over three weeks demanding the release of Suu Kyi, 75, and recognition of the result of last year's election.
In Yangon, riot police fired rubber bullets, stun grenades and shots into the air on Friday to send protesters scattering. At least one person was wounded there, a witness said.
Several people were also hurt by police in the second city of Mandalay, media said. Police also broke up protests in Naypyitaw and other towns, witnesses said.
Military chief General Min Aung Hlaing says authorities were using minimal force. Nevertheless, at least three protesters have died. The army says a policeman was also killed.
At least 771 people are under detention or have outstanding charges that have been laid against them since the coup, according to Myanmar's Assistance Association for Political Prisoners.
Suu Kyi, the daughter of Myanmar's independence hero, spent nearly 15 years under house arrest under previous juntas. She faces charges of illegally importing six walkie-talkie radios and of violating a natural disaster law by breaching coronavirus protocols.
The army has promised an election, but has not given a date. It has imposed a one-year state of emergency.
The question of an election is at the centre of a diplomatic effort by the Association of Southeast Asian Nations (ASEAN), of which Myanmar is a member. Indonesia has taken the lead, but coup opponents fear the efforts could legitimise the junta.
ASEAN foreign ministers are planning to hold a meeting on Myanmar soon, regional diplomats said.
(Reporting by Reuters Staff; Writing by Robert Birsel; Editing by Richard Pullin)
Author adminPosted on February 27, 2021
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Boxe : Duhaupas prévient Yoka !
US: Outrage over cartoon equating mask requirement to Holocaust
Coronavirus : des enfants réalisent un clip sur la chanson de Calogéro pour dire merci aux soignants
ЦПВС сообщил об обстрелах террористами населенных пунктов в Идлибе
952 bestätigte Corona-Fälle


If you have been arrested for Driving Under the Influence (DUI) involving Prescription or Illegal Drugs in the Columbus Ohio Area, or its surrounding counties, contact the Rutan Law Firm for specific information and expertise on DUI cases connected with Prescription or Illegal Drugs.
Driving Under the Influence is just that – driving under the effect of a substance that impairs your normal faculties, and can include driving under the influence of alcohol, prescription drugs, illegal drugs, or even over-the-counter drugs and medications. Although drivers in the State of Ohio typically think of DUI as involving the consumption of alcohol, in fact, drivers can also be arrested for DUI if they are believed to be impaired by Prescription or Illegal Drugs.
Being arrested for DUI involving Prescription or Illegal drugs carries the additional predicament of also potentially facing an arrest and conviction for Drug Possession. Thus, your attorney should have experience in both areas to provide you with the best counsel.
When law enforcement stops you for suspicion of DUI, they must establish that your normal faculties are impaired or your breath / blood alcohol content (BAC) is .08 or higher utilizing a DUI breath test. Typically, individuals under the influence of Prescription or Illegal Drugs will not register an illegal breath / blood alcohol content level (unless they have also been drinking). Thus, law enforcement officers are forced to establish that your normal faculties are impaired using Field Sobriety Tests (FSTs) and determine the presence of Prescription or Illegal Drugs utilizing a DUI urine test, or a DUI blood test.
To further complicate matters, there are complex scientific issues concerning the identification of active ingredients of drugs in both urine and blood testing. Additionally, it is difficult to ascertain whether or not the substance identified was an active or an inactive metabolite at the time of testing. There is also a human variable to add to the equation – each individual has unique tolerances to Prescription or Illegal Drugs that can significantly influence their actual level of impairment regardless of the empirical result of the urine test.
All of the complexities related to Prescription and Illegal DUI arrests make for good defenses and may potentially influence the outcome of your case. In fact, even the National Highway Traffic Safety Administration recognizes the inherent complexities of establishing a relationship between a person's blood or plasma concentration of a Prescription or Illegal Drug and performance impairing effects.
Although Prescription Drugs (prescribed to you) are legal, you may still be arrested for DUI while under the influence of a Prescription Drug. All Prescription Drugs include warning labels that often caution that the substance may, "Cause Drowsiness or Dizziness," or that the consumer should, "Use Care When Operating a Motor Vehicle or Heavy Machinery." Others go a step further and warn that the consumer should not operate a motor vehicle while utilizing the Prescription Drug. While the warning labels state cautions, they do not indicate that you can be arrested for DUI while using your legal medication. It is important to establish that you were within the "therapeutic range" of the Prescription Drug in question.
Don't speak to the police – ask to have an attorney present.
Don't give a written statement – again, ask to have an attorney present.
Collect and document your own evidence.


SHE grew up playing touch football, so making the transition to play club rugby league was supposed to be an exciting new challenge for Jess Carstens.
The 29-year-old never got to represent the Sunshine Coast Falcons.
It was only her fourth game of league pre-season and during a trial match for the Falcons on April 8 she took a tackle so hard the Nambour Crushers fullback would never return to the field for another game.
"I made the tackle," Ms Carstens said. "I remember hitting the ground and feeling my pelvis go hot...my legs went out straight and I couldn't move.
"I had to get up though, quickly, because the game was going to run over the top of me. I just took painkillers and iced it thinking it was a cork. I went back on after a bit to finish the game."
Ms Carstens said she didn't realise the damage caused until she found herself in hospital two days later.
She had severely damaged her left sacroiliac joint, the foundation supporting her spine; ruptured a disc and tore her sciatica nerve. After trying physiotherapy, a chiropractor, acupuncture and a CT guided spinal that caused her 10 days of the "most excruciating pain of her life", recent results from the doctors revealed her condition was still deteriorating, fast.
"I will need to have radiofrequency neurotomy surgery; an injection that gets rid of all the nerves which eases some of the pain."
But for only a 30-50 per cent long-term success rate, the procedure will cost about $8000. It's money that Ms Carstens doesn't have, given she can no longer work.
"My football insurance won't pay up front; they reimburse 80 per cent of the costs but I have to pay up front first.
"And it only pays for about $5000 of treatment, $1500 of that I have already used for treatment."
Ms Carstens said she was trying to get her superannuation fund to release some of her benefits early on compassionate grounds. "I'm only young, I don't want to dig into my super...but what else can I do?
"This whole experience has been life-changing; you go from training for three hours every day and living your life to wondering whether you will be able to get out of bed the next day because of the pain.
"I can't work, I can't play football; I can't even make plans without knowing what the day will be like."
Ms Carstens said she hadn't give much thought to what her life would be like after surgery, and just wanted to tackle one hurdle at a time.
A GoFundMe page has been set up for Ms Carstens by her personal trainer and friend, Simone Sullivan.
"(Jess) is a force to be reckoned with and the girl who lights up the whole room when she enters," Ms Sullivan said.
"She has an infectious personality that leaves you wanting more and is always leaving a positive impact on those around her. Any donations will go towards paying for Jess's surgery, her recovery and rehabilitation."


Is a VDI environment more secure than a traditional environment? Or is it just a solution for better management of your desktops? Is it more or less secure than a terminal server based environment?
Is having antivirus incorporated in the hypervisor better for security or is it just providing easier management?
How do you protect the access clients?
All these topics are being discussed in this roundtable podcast. Well worth a listen.
Sound quality is not optimal all the way through the podcast, but it's still a good discussion.
Virtualization Security Roundtable, episode 73 "Virtual Desktop Security"
The video here is the view from my bedroom window.


text:
Copelatus carayoni es una especie de escarabajo buceador del género Copelatus, de la subfamilia Copelatinae, en la familia Dytiscidae. Fue descrito por Legros en 1949.

Referencias

carayoni