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Measurement of the pubic portion of the levator ani muscle in women with unilateral defects in 3-D models from MR images
- Adele Hutchinson
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1 International Journal of Gynecology and Obstetrics (2006) 92, CLINICAL ARTICLE Measurement of the pubic portion of the levator ani muscle in women with unilateral defects in 3-D models from MR images L. Chen a, *, Y. Hsu b, J.A. Ashton-Miller a, J.O.L. DeLancey b a Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, USA b Division of Gynecology, Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, Michigan, USA Received 6 September 2005; received in revised form 16 November 2005; accepted 1 December 2005 KEYWORDS Levator ani; Muscle; Injury; Cross-sectional area; MR image; 3-D reconstruction Abstract Objective: Develop a method to quantify the cross-sectional area of the pubic portion of the levator ani muscle, validate the method in women with unilateral muscle defects, and report preliminary findings in those women. Method: Multi-planar proton density magnetic resonance images of 12 women with a unilateral defect in the pubic portion of their levator ani were selected from a larger study of levator ani muscle anatomy in women with and without genital prolapse. Three-dimensional bilateral models of the levator ani were reconstructed (using 3-D Slicer, version 2.1b1) and divided into iliococcygeal and pubic portions. Muscle cross-sectional areas were calculated at four equally spaced locations perpendicular to a line drawn from the pubic origin to the visceral insertion using the I-DEASR computer modeling software. Results: The crosssectional area of the muscle on the side with the defect was smaller than the normal side at all the four locations. The average bilateral difference was up to 81% at location 1 (nearest pubic origin). Almost all of the volume difference (13.7%, P =0.0004) was attributable to a reduction in the pubic portion (24.6%, P b ), not the iliococcygeal portion ( P =0.64), of the muscle. Conclusions: A method was developed to quantify cross-sectional area of the pubic portion of the levator ani perpendicular to the intact muscle direction. Significant bilateral cross-sectional area differences were found between intact and defective muscles in women with a unilateral defect. D 2005 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. * Corresponding author. University of Michigan, Biomechanics Research Lab, 2350 Hayward Street, 3216 GGBrown, Ann Arbor, MI , USA. address: (L. Chen) /$ - see front matter D 2005 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi: /j.ijgo
2 Measurement of the pubic portion of the levator ani muscle in women with unilateral defects Introduction Pelvic organ prolapse and urinary incontinence can be debilitating problems, with one in nine women [1] facing the probability of surgery during their lifetime for these problems. Although the disease mechanism responsible for organ prolapse is not fully understood, injury and deterioration of muscle, nerve and connective tissue are believed to play a role in altering normal pelvic organ function [2 5]. Visible defects of levator ani muscle have been observed in MR images of women after vaginal delivery [6] and also women with pelvic floor dysfunction [7 9]. The maximum force developed by skeletal muscle is related to its cross-sectional area measured perpendicular to muscle fascicle direction and ranges from 4 to 8 kgf/cm 2 [10,11]. Therefore the cross-sectional area measurement perpendicular to muscle fascicle direction is an important morphological determinant of muscle capacity. The levator ani muscle has a complex shape with the muscle fibers in the pubic portion of the levator ani muscle running in a different direction than those in the iliococcygeal muscle [12 14]. Therefore, the two regions must be separated prior to crosssectional area measurements. Also, the muscle fibers do not run perpendicular to standard MR scan slices, so levator cross-sectional area measurements cannot be properly performed on standard 2-D MR images. The goal of this study was to first develop a method for quantifying the cross-sectional area of pubic portion of the levator ani muscle perpendicular to its muscle fascicle direction. Then, the method was used to quantify the loss in crosssectional area in women with visible unilateral levator ani defects by comparing normal muscle on one side with abnormal muscle on the other side in the same individual. To validate this new method, the null hypotheses were tested that there would be no difference in cross-sectional area between the defect and normal sides, nor would there be a difference in cross-sectional area along the length of the muscle. through advertisements as well as through the Women s Health Registry. Patients were excluded if they had previous surgery for prolapse or incontinence, genital anomalies, or had delivered in the past year. Women with visible unilateral defects in the pubic portion of the levator ani muscle on MR imaging were selected so that, within the same individual, normal muscle morphology on one side could be compared with abnormal muscle morphology on the other side (Fig. 1). This approach circumvents the problem of inter-individual differences in muscle appearance and bulk. Among the 12 women who were selected, five had prolapse of one vaginal wall or cervix at least 1 cm below the hymen; seven had normal support of all pelvic structures with no vaginal wall lower than 1 cm above the hymen as assessed by clinic evaluation (POP-Q [15]). The average age was 56.2 FSD 11.9 years and average BMI was 27.3FSD 4.0 kg/ m 2. Parity ranges from one to six vaginal deliveries with a median of three. Ten additional women with normal intact levator ani muscles on MR images were selected as a control group to validate the method. Five had prolapse and five had normal pelvic organ support. The average age was 62.5 F SD 3.34 years and average BMI was 27.5FSD 5.0 kg/m 2. Parity ranges from one to six with a median of three. Multi-planar, two-dimensional, fast spin, proton density MR images (echo time 15 ms, repetition time 4000 ms) were obtained using of a 1.5 T superconducting magnet (General Electric Signa Horizon LX, GE Medical System, Milwaukee, Wis) with version 9.1 software. The axial and coronal 2. Methods A convenience sample of 12 women with a unilateral levator ani muscle defect was selected from an IRB-approved study comparing muscle anatomy in women with prolapse and women with normal pelvic organ support. The prolapse patients were recruited through the University of Michigan Urogynecology Clinic. The controls were recruited Figure 1 Axial proton density MR image of a woman with a right unilateral defect. The left levator ani muscle is intact (denoted by *) while the right side portion of the muscle is missing. PB denotes pubic bone; U: urethra; V: vagina; R: rectum; OI: obturator internus muscle.
3 236 L. Chen et al. Figure 2 (A) Reconstructed 3-D model showing the pubic bone and levator ani muscle with a right unilateral defect. (B) The dashed region shows the expected location of the missing muscle after reflecting the muscle from the normal side across the midline. fields of view were each cm while in the sagittal images, it was cm. All three views had slice thicknesses of 4 mm with a 1 mm gap between slices. Axial, sagittal and coronal MR images were imported into a three-dimensional (3-D) imaging program (3-D Slicer, version 2.1b1, Brigham and Women s Hospital, Boston, MA) and aligned using Figure 3 Separating the pubic portion of levator ani from the iliococcygeus portion on MR scans. A): Identification of the middle point (triangle) on the mid-sagittal MRI; B) and C): identification of the two lateral points on MRI (cross and diamond). The following structures were identified in MRI to help for orientation. PS denotes pubic symphysis; PB: pubic bone; B: bladder; A: anus; OI: obturator internus; U: uterus (with fibroids); PRM: puborectalis muscle. ICM: iliococcygeus muscle. Figure 4 3-D view of the separation of the pubic portion from the iliococcygeal portion of the levator ani. The dashed line represents the plane of separation, while the triangle, cross and diamond have the same meaning as in the preceding figure.
4 Measurement of the pubic portion of the levator ani muscle in women with unilateral defects 237 anatomic landmarks (arcuate pubic ligament, pubic bone, pubic symphysis, etc.). 3-D volume-rendering models were generated from axial and coronal planes and then imported into I-DEAS version 9.0 (UGS, Plano, TX), an engineering graphics program (Fig. 2A). The levator ani was separated in the midline and then designated as either bnormalq or bdefectiveq side. Within 12 women, five had defective muscles on the left side and seven had defective right sided muscles. A model of the normal muscle (dashed outline) was reflected about the mid-sagittal plane and superimposed on the contralateral defective side in order to visualize the area of missing muscle (Fig. 2B). The pubic portion of the levator ani muscle was separated from the iliococcygeal portion by establishing a dividing plane through three anatomical landmarks identified independent of muscle presence or absence (Figs. 3 and 4). One middle landmark was defined as the upper aspect of the puborectalis bbumpq [16] on the mid-sagittal slice (Fig. 3a). Two lateral landmarks for the plane were defined as the most medial origin of the iliococcygeus from the arcus tendineus levator ani (ATLA) (Fig. 3b and c). There is evidence that the pubic portion of the levator ani has muscle fascicles oriented parallel to the line-of-action of the muscle between its origin and insertion [17]. The fascicle direction was not directly observable on the MR scans, so it was approximated by establishing a line between the middle of the origin point and the center of the insertions using anatomic landmarks. These landmarks were chosen to be independent of muscle presence or absence, and were based on anatomical literature [13], MR imaging [16] and Figure 6 Lines connecting the origin and insertion points (see preceding figure) were used to estimate muscle fiber direction. The dashed region shows the expected location of the muscle on the defective side, were it intact. the senior author s dissection experience. The muscle origins were defined in axial MR images as being 1.5 cm above the arcuate pubic ligament, and 0.2 cm medial from the obturator internus insertion on the left and right pubic rami. The insertion points were defined bilaterally in the sagittal plane as the center of the intersphincteric groove on slices 0.5 cm lateral to the mid-sagittal slice (Figs. 5 and 6). Using I-DEAS, five equally spaced cross-sectional were made perpendicular to the fiber direction line and were numbered from d1t at the pubic origin to d5t at the insertion end (Fig. 7). Since location 5 lay dorsal to the edge of the muscle, Figure 5 Reference points for determining fiber direction in the pubic portion of the levator ani. A) Origin points on axial MR at its junction with obturator internus (OI) as open circle on patient s left and filled circle on patient s right; B) and C) right (filled square) and left (open square) insertion point on sagittal MR scans. The following structures are identified aid orientation. PB: pubic bone; B: bladder; V: vagina; R: rectum; A: anus.
5 238 L. Chen et al. Figure 7 Methodological steps to quantify levator ani muscle loss in a subject with a unilateral defect. A: Frontal view of the 3-D reconstruction model of levator ani was built. B: The pubic portion is separated from the iliococcygeal portion; here only the pubic portion is shown. C: The line of estimated fiber direction of the pubic portion was determined. Equally spaced cutting planes perpendicular to the fiber direction line were placed. D: The resulting crosssections are shown. Cross-sectional areas were then calculated. Due to the defect on the right, muscle is not present at location 1; therefore, it is not shown. cross-sectional areas were only calculated bilaterally for locations 1 4. Fig. 7 shows a graphical demonstration of the sequence of steps used to quantify the unilateral levator ani muscle loss. Two-sided paired t-tests were used to compare for bilateral differences in cross-sectional area and volume, with P b 0.05 being considered statistically significant. One might hypothesize that the fiber direction of the remaining muscle could change due to the presence of the defect and the use of the normal fiber direction may cause some error in estimation of the cross-sectional area of the remaining muscle. Therefore, a secondary analysis was performed by curving and rotating the normal muscle fiber direction line to best fit the remaining muscle model. The cross-sectional area perpendicular to remaining muscle fiber direction was compared with the initial results using a paired t- test (Fig. 8). The volumes of both the pubic portion and iliococcygeal portion of levator ani muscle on the normal and defective sides were also calculated as a secondary outcome. 3. Results In the 10 women with normal levator ani muscle, there was not a significant difference between left and right cross-sectional areas at any location (Table 1). In the women with a unilateral defect, the defective side had a significantly smaller muscle cross-sectional area at each location in the pubic portion of the levator ani (Fig. 9). However, the extent of the cross-sectional area loss differed depending on location. The largest mean crosssectional area loss (81%, P =0.0002) was near the pubic origin (location 1), while near the insertion Figure 8 A: Cross-sectional area perpendicular to dnormalt muscle direction; B: Cross-sectional area perpendicular to remaining muscle direction.
6 Measurement of the pubic portion of the levator ani muscle in women with unilateral defects 239 Table 1 Comparison of meanfstandard error of the mean cross-sectional area (CSA) in cm 2 of left and right side in ten women with normal muscle Location 1 Location 2 Location 3 Location 4 CSA of left side (cm 2 ) 1.30F F F F0.21 CSA of right side (cm 2 ) 1.20F F F F0.19 P-value (location 4) the loss in mean cross-sectional area was not statistically significant (13.5%, P = ; post hoc power=25%). There was no statistically significant difference in the cross-sectional areas calculated using the bnormalq fiber direction compared to the fitted remaining fiber direction (Table 2), thereby validating the use of the bnormalq fiber direction on the defective side. The overall volume of the levator muscle was 13.69% smaller on the defective side (17.96 F 1.4 cm 3 ) than on the normal side (20.81F1.35 cm 3, P = ). This was primarily attributable to a reduction in the pubic portion of levator ani muscle (defective side: 9.16F0.83 cm 3 ; normal side: 12.19F0.71 cm 3, a 24.6% volume reduction, P b ), while the iliococcygeal portions were not significantly different (defective side: 8.80 F 1.25 cm 3 ; normal side: 8.62 F1.12 cm 3, P =0.64, post hoc power=7%). 4. Discussion This new method allows levator ani muscle crosssectional area to be measured perpendicular to the fascicle direction, which was assumed parallel to the line-of-action of the pubic portion of the Figure 9 Bilateral comparison of muscle cross-sectional area of pubic portion of levator ani muscle perpendicular to its fiber direction. Bars are standard error and * denotes P b0.05. levator ani muscle. This is important because maximum muscle strength is proportional to cross-sectional area, not thickness or volume. Since it was demonstrated that there was no bilateral difference in cross-sectional area in normal pubic portion of the levator ani muscle, having a normal muscle on one side and a visibly defective muscle on the other side within the same individual offers a unique opportunity to validate the method s capability for detecting the magnitude of any bilateral cross-sectional area differences. Since the levator ani muscle damage usually appears in localized regions, and more often in the pubic portion rather than in the iliococcygeal portion [6], focus was placed on quantifying the cross-sectional area in the pubic portion to increase the sensitivity of the method for identifying muscle defects. The finding of a smaller volume in the pubic portion, but not in the iliococcygeal portion, shows that our method of separating the two parts of the muscle was effective in isolating the defective area. Muscle fascicle direction in the pubic portion was determined independent of muscle presence by identifying muscle origin and insertion. A smaller cross-sectional area was found in the defective muscle near the pubic origin corresponding to the anatomical location of the visible MR defect. Since no visible defects were evident in the iliococcygeus muscle, calculations of its cross-sectional area were omitted for the sake of brevity. Several techniques have been used to quantify levator ani muscle morphology. Bernstein used perineal ultrasonography to visualize and measure the thickness of levator ani muscle [18]. However, because image resolution was limited, it is not clear which portion of the levator ani muscle was measured or what angle of fiber direction was used. Aukee et al. measured the thickness of the distal part of the pubococcygeal in static axial MR image and found it to be significantly correlated with EMG values during a maximal contraction [19]. This measurement only reflects one dimension of the muscle and the relationship of this dimension to fiber direction is not known. Hoyte et al. quantified the levator ani muscle volume and levator ani angle using 3-D reconstructed models [20]. Although volumetric techniques can provide a measurement
7 240 L. Chen et al. Table 2 Comparison of meanfstandard error of the mean cross-sectional area (CSA) in cm 2 calculated using bnormalq fiber direction with that calculated using remaining fiber direction Location 1 Location 2 Location 3 Location 4 CSA perpendicular to dnormalt muscle direction 0.19F F F F0.18 CSA perpendicular to remaining muscle direction 0.24F F F F0.20 P-value of morphologic change, quantifying muscle crosssectional area normal to its assumed fascicle direction, as done in this study, is more appropriate from a biomechanical perspective. The smaller the muscle cross-sectional area, the smaller the maximum contractile force it can develop in that region. Volume results are provided in this paper in case it is later found that the pennation angle of the pubic portion of levator ani muscle fibers is non-zero. In that case, the physiological crosssectional area of the muscle can be found by dividing the volume by the product of muscle fiber length times the cosine of the pennation angle. The complex shape and fiber arrangement of the levator ani muscle precludes useful measurements of the muscle being made in standard MR imaging planes (i.e., axial, sagittal and coronal plane slices) because slice angle variation in 2-D static MRI scans can cause measurement variations of up to 15% [21]. Therefore 3-D reconstruction and establishment of muscle fascicle direction in 3-D space is preferred for cross-sectional area measurements aimed at estimating the maximum potential to develop muscle force. There were several challenges in developing this measurement method. The first was in separating the levator ani into two portions. There are some small regions of the muscle where the iliococcygeal and the pubic portions overlap, for example, behind the rectum. [12] Therefore separation of the pubic and iliococcygeal portions of the muscle did not preclude the possibility for inclusion of a small portion of the iliococcygeal muscle in the pubic portion, and vice versa. Further refinements in the technique may allow more accurate separations to be made in the future. Identification of muscle fascicle direction was also a challenge. It was not possible, at present, to consistently see individual fascicles or fibers within the pubic portion of the levator. The straight line used to approximate muscle fascicle direction from the muscle origin to insertion point allows one to circumvent this problem. However, some muscle fibers did not follow this approximate fiber direction. For example, cross-sectional areas calculated at location 4 were not strictly perpendicular to the fiber direction as some fibers cross the midline at this point. This problem did not affect locations 1, 2 or 3. There was also concern that a defect might also affect the remaining fiber direction; however, the results showed that the differences in measurements using an alternative assumption for fiber direction were not statistically significant (Table 2). This method for measuring muscle cross-sectional area should help investigators assess one morphological, and hence biomechanical, feature of the levator ani muscle. For example, this type of approach may yield insights into the role of levator ani muscle defects in the development of pelvic floor dysfunction. The method was validated using women with unilateral defects and can be applied to patients with both normal muscles and injured muscles. Acknowledgment The support of a grant from NICHD (R01 HD-38665) is gratefully acknowledged. References [1] Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89: [2] Boreham MK, Wai CY, Miller RT, Schaffer JL, Word RA. Morphometric analysis of smooth muscle in the anterior vaginal wall of women with pelvic organ prolapse. Am J Obstet Gynecol 2002;187: [3] Boreham MK, Wai CY, Miller RT, Schaffer JL, Word RA. Morphometric properties of the posterior vaginal wall in women with pelvic organ prolapse. Am J Obstet Gynecol 2002;187: [4] Takano CC, Girao MJ, Sartori MG, Castro RA, Arruda RM, Simoes MJ, et al. Analysis of collagen in parametrium and vaginal apex of women with and without uterine prolapse. Int Urogynecol J 2002;13(6): [5] Smith ARD, Hosker GL, Warrell DW. The role of partial denervation of the pelvic floor in the etiology of genitourinary prolapse and stress incontinence of urine: a neurophysiologic study. Br J Obstet Gynaecol 1989;96: [6] DeLancey JO, Kearney R, Chou Q, Speights S, Binno S. The appearance of levator ani muscle abnormalities in magnetic resonance images after vaginal delivery. Obstet Gynecol 2003;101(1):46 53.
8 Measurement of the pubic portion of the levator ani muscle in women with unilateral defects 241 [7] Kirschner-Hermanns R, Wein B, Niehaus S, Schaefer W, Jakse G. The contribution of magnetic resonance imaging of the pelvic floor to the understanding of urinary incontinence. Br J Urol 1993;72: [8] Tunn R, Paris S, Fischer W, Hamm B, Kuchinke J. Static magnetic resonance imaging of the pelvic floor muscle morphology in women with stress urinary incontinence. Neurourol Urodyn 1998;17(6): [9] Singh K, Jakab M, Reid WM, Berger LA, Hoyte L. Threedimensional magnetic resonance imaging assessment of levator ani morphologic features in different grades of prolapse. Am J Obstet Gynecol 2003;188(4): [10] Ikai M, Fukunaga T. Calculation of muscle strength per unit cross-sectional area of human muscle by means of ultrasonic measurement. Int Z Angew Physiol Einschl Arbeitsphysiol 1968;26(1): [11] Ikai M, Fukunaga T. A study on training effect on strength per unit cross-sectional area of muscle by means of ultrasonic measurement. Int Z Angew Physiol Einschl Arbeitsphysiol 1970;28(3): [12] Lawson JO. Pelvic anatomy: I. Pelvic floor muscles. Ann R Coll Surg Engl 1974;54: [13] Kearney R, Sawhney R, DeLancey JO. Levator ani muscle anatomy evaluated by origin-insertion pairs. Obstet Gynecol 2004;104(1): [14] Singh K, Reid WM, Berger LA. Magnetic resonance imaging of normal levator ani anatomy and function. Obstet Gynecol 2002;99(3): [15] Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JO, Klarskov P, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;175(1):10 7. [16] Strohbehn K, Ellis JH, Strohbehn JA, DeLancey JOL. Magnetic resonance imaging of levator ani with anatomic correlation. Obstet Gynecol 1996;87(2): [17] Janda S, van der Helm FC, de Blok SB. Measuring morphological parameters of the pelvic floor for finite element modelling purposes. J Biomech 2003;36(6): [18] Bernstein IT. The pelvic floor muscles: muscle thickness in healthy and urinary-incontinent women measured by perineal ultrasonography with reference to the effect of pelvic floor training. Estrogen receptor studies. Neurourol Urodyn 1997;16(4): [19] Aukee P, Usenius JP, Kirkinen P. An evaluation of pelvic floor anatomy and function by MRI. Eur J Obstet Gynecol Reprod Biol 2004;112(1):84 8. [20] Hoyte L, Schierlitz L, Zou K, Flesh G, Fielding JR. Twoand 3-dimensional MRI comparison of levator ani structure, volume, and integrity in women with stress incontinence and prolapse. Am J Obstet Gynecol 2001;185(1): [21] Hoyte L, Ratiu P. Linear measurements in 2-dimentional pelvic floor imaging: the impact of slice tilt angles on measurement reproducibility. Am J Obstet Gynecol 2001; 185:
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It's not over until the fat lady sings—at least not in major UK museums and galleries next year when opera goes under the spotlight. The Victoria and Albert Museum is teaming up with the Royal Opera House for its inaugural show—Opera: Passion, Power and Politics (30 September-25 February 2018)—in the new Sainsbury Gallery, a major exhibition space at the heart of the museum's long-awaited, new Exhibition Road building project which is due to open in July. "The exhibition will focus on seven opera premieres, seven opening nights in seven distinct cultural landscapes, which culminate in the international explosion of opera in the 20th and 21st century," a press statement says. These include Venice (Monteverdi's L'Incoronazione di Poppea, 1642) and London (Handel's Rinaldo, 1711). Meanwhile, the Photographers' Gallery in London will launch Four Saints in Three Acts next autumn (27 October-February 2018), focusing on the eponymous 1934 production which was the first opera staged on Broadway (but not many people know that the opera debuted at the Wadsworth Atheneum Museum of Art in Connecticut first). The production, composed by Virgil Thomson, also broke new ground with its all African-American cast. "[The opera] significantly influenced public perceptions of modernist experimentation, avant-garde art, and African-American involvement in white American culture," the organisers say. The new exhibition will include top-notch portrait and documentary shots by photographers such as Lee Miller and George Platt Lynes.
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Zebrafish with defective Nodal signaling have a phenotype analogous to the fatal human birth defect anencephaly, which is caused by an open anterior neural tube. Previous work in our laboratory found that anterior open neural tube phenotypes in Nodal signaling mutants were caused by lack of mesendodermal/mesodermal tissues. Defects in these mutants are… (More)
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We examined the development of striped and spotted pigmentation by comparing and contrasting wildtype zebrafish (striped) with fish carrying the leopard mutation (spotted). We hypothesized that WT and leopard mutant fish would differ in pigmentation during larval and juvenile stages. Surprisingly, we found that the pigment formed similar complex but ordered… (More)
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Hey all, I figured I should introduce myself since I plan on being pretty active on the IGN community boards and blogs in the future.
My name is Bill Montoya and I'm a college student at the moment in the State of Utah. I'm on my last leg of college, doing my student teaching so I can start looking for a job. I am a semi-new parent, my son is a one year old, and I've been married for two years. My family is a great inspiration to me, and I love to write and game when I'm not spending time with them.
I have a degree in teaching physical education and coaching for secondary grade levels, but I plan on getting my English minor as soon as I land a job. It is my love for writing that has given me the drive to push for that minor, so I can hopefully instill this love for writing in my future students.
My background with games stemmed all the way back with the Original Nintendo, and my very first cartridge was Mario w/ Duck Hunt, and my second was Zelda! I have been an avid gamer ever since and have owned nearly every console since in some capacity. Because of the new family addition and such, I don't have nearly as much time to get immersed in the gaming world, but I would love to get back into it if it were made available as a job.
Game genres I enjoy:
- RPG's
- Final Fantasy's (all of them,) Chrono Trigger, many of the strategy ones like Ogre Tactics, Disgea, etc...
- Sports Games
- Madden, MLB: The Show, NBA2K series, FIFA, NHL, really just about any sports game
- Adventure games
- Any Zelda game, God of Wars are great, etc...
There are many more games, and I don't care to list them all as this is intended to be a brief introduction.
If there's anything else you would like to know about me, feel free to ask!


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|News & Politics
Because there's a war on for your mind; veteran broadcaster, filmmaker and media analyst Alex Jones brings you incredible interviews with people on the frontlines of the Infowar and takes an in-depth look at the news between the day's headlines.
August 18th, 2015
Episode 262 of 868 episodes
On this Tuesday, August 18 edition of the Alex Jones Show, we report on Trump's battle with pro-amnesty supporters, including Facebook CEO Mark Zuckerburg. Trump has now pulled clear of his Republican competition according to a new poll. On today's show Alex debates white nationalist David Duke on a variety of current topics in national news. Also, WND journalist Michael Maloof explains how Obama willfully allowed the rise of ISIS in the Middle East. Other topics covered include the LGBT lobby trying to ban public schools from using the words 'boy' and 'girl' as well as the Danish politician convicted of 'racism' for offending Muslims. Tune in!
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Welcome to the Brain Training Podcast, the daily audio workout for your head. In this podcast we have two games for you, each with three rounds which get progressively harder. To enjoy the full experience, relax, and avoid distractions whilst you listen.


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RepairPal is your advocate for car care advice and guidance
Q: Do the struts cause the clanking noise on bumpy roads? on 2001 Dodge Grand Caravan
I was told the struts are causing the clanking when I drive over bumps in the road. Doesn't sound so bad on the interstate though. They told me they replaced the struts but sound was still there. Then they said it was the wheel bearing "just needs greasing". Struts or wheel bearing?
Before you invest in replacing struts, replace your Sway Bar Bushing first. They are inexpensive and take about 1/2 hour to install. The Sway bar links can also cause this noise so you may want to do both at the same time depending on your budget.
Sounds to me like it could be tie rods or sway bar links.
You may want to check your engine mounts. I have an 04 grand caravan that was doing the same thing and it turned out to be the left front engine mount; the one closest to the radiator. Part for the fix was $34.00 from Napa.
it the struts tower bearing my friend did the same thing on mine
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Here are some photos of our 4th Artist's Date yesterday. We spent the morning sketching or painting a lovely floral arrangement donated to us by Cornelius Flowers in Tomball. In the afternoon Bill Epps gave two demonstrations; how to draw perspective and how to paint an under-painting for your watercolor painting.
Drop your chores, pick up your art supplies and your lunch, and come and enjoy a mellow day at the library with other Adult artists. We've been doing this about every six months--this is our fourth 'date', and it's a lovely time to meet other artists in the community and do a little of the painting or sketching that you might otherwise leave until all your other pressing activities are complete!
We'll meet at about 10:00 a.m. (or whenever you get here) to do our own thing for the morning. Then we'll break for lunch (the library will provide a light dessert and coffee). Afterwards, Bill Epps, a retired architect, will give us a demonstration about various aspects of painting architectural features in watercolor. I don't know everything he plans to do, but learning how to draw in perspective and how to paint an effective under-painting are on the list.
We'll be in the area at the front of the library that we call the 'Sun Room'; behind the elevators and between the Westerns and the CD Audiobooks. Join us if you can!
A couple of times a year we invite adult artists to the library to paint together, enjoy each other's company, and watch an artist demonstration. Imagine a lovely spring morning; you are standing at your easel or sitting at a table in our sunny front room among other artists. Warm conversation gradually fades into an embracing communal silence as each artist happily focuses on his or her work. Outside, the college's dominant male crow struts up to the window and engages in a percussive battle with his reflection in the glass. The college caterer silently slips in with coffee, water, and dessert. As people get hungry, they put down their implements, open their lunches, and conversation picks up again. After lunch, an artist, this time, retired architect Bill Epps, Jr., gives a relaxed demonstration of his watercolor painting technique. Is this for you?
Then mark your calendar for Thursday, April 23rd, from 10 a.m. to 3 p.m. See you then!
Drop your chores, bring your lunch and your art supplies, and join us in the front room of the library for our summer Artist's Date Thursday, August 7th. Beginning at 10:00, we'll spend the morning doing our own art project; then we'll have lunch, and at 1:00, artist Gabe Riquelme will help us learn how to do believable figure drawing.
Just to let you know: we WILL be hosting an Artist's Date to cap off the end of our Summer Reading Program in August! Science is the theme of this year's Summer Reading Program, so we will be featuring the 'science' of drawing the figure as our Artist's Date theme.
Adult artists, on Thursday this week, drop your chores, bring your art supplies and your lunch and enjoy a relaxing day with other artists. We'll spend the morning painting or sketching a still life in the sunny front room of the library, enjoy each other's company over lunch, and in the afternoon, we'll go up to the computer lab and practice working with reference photos using basic Microsoft Office tools. That's this Thursday, January 16, from 10 am to 3 pm--or whatever fraction of that you can come. All free; no registration needed.
Adult artists! Drop your morning chores, pack up your art supplies and your lunch, and come to the library to enjoy a day of sketching or painting with other adult artists--next Wednesday, July 10th, from 10 a.m. to 2:30 p.m. We will provide easels, still life objects, clothed models, dessert and beverages; and after lunch, Judy Crowe, an accomplished local oil painter and instructor, will give a demonstration. We'll be in the library first floor front room and then Room L 129 for lunch and the demo. Call 823-559-4213 for more information. There's no registration and no fee.
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A complete guide by Montana Fine Woodworker Scott Morrison
The complete guide to learning how to build your own rocking chair. Don't let the beauty and elegance of this rocker intimidate you. I've filmed nearly 6 hours of highly detailed instruction, so that any woodworker will be able to successfully complete this wonderful and rewarding project.


text: Matt Walker May 06, 2009 10:36 PM The only thing lacking with the current BTCC is manufacturers - and this factor doesn't determine how entertaining the series is. In terms of racing, variety of cars, calibre of drivers - it's arguably somewhere near it's best. Certainly no complaints from me. Reply Report abuse 5 agree 1 disagree


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POSTED BY: RICHARD SHERMAN in BLOG
12s, you already know you are the best fans in the world! I just wanted to take the time to say we all appreciate your loyalty and love. This team wouldn't be the same without you. We feed off your energy during games at Clink. Even at away games we hear the traveling fans loud and proud. Can't imagine playing for any other set of fans in this league!
Bleed Blue and Green in my new Tees!
As a tribute to the most loyal fans in the NFL, Hawks President Mike McCormack retired the number 12 jersey on Dec 15, 1984 forever. To this day, you all have continued to live up to the title of the 12th man. You've caused the earth to shake during our playoff game against the Saints in 2011, when Marshawn scored a 67-yard touchdown. Again, against the Saints, in Dec 2013 you almost made my eardrums rupture. You got the second loudest recording in the world at 137.6 decibels. Eardrums rupture at 150 decibels, that's nuts... not sure if I want my ears to stop working, but it'd probably be worth it.
I love reading all your comments on my site and social media platforms. They bring me such motivation and inspiration to keep giving it my all for you. Every time I take the field, whether at home at the Clink or on the road, your presence is undeniable. Thank you for being our 12th man and the loudest fans in the world!
Can't wait to get back in front of you all this weekend vs. the Bears at the Clink. I got a couple tickets to give out to the opener! Every order from my site automatically enters you in for a chance to win them. Check out my gear here!
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Thomas and Friends The Trackmaster Series is SuperMalechi's Trackmaster Model Series.
The series focuses on the Steam Team (Thomas, Edward, Henry, Gordon, James, Percy, Toby, Duck, Donald & Douglas, Oliver, Emily, Molly, Eagle and Kenny). The first two seasons have a sing-along segment in each episode.
Steam Team
- Thomas - A blue tank engine, who is the main star of the show. He's a bit cheeky, and helpful to the others. His rival is James. And his ex-rivals are Diesel and Diesel 10. He has an girlfriend named Emily. And he also has two coaches named Annie and Clarebel.
- Edward - A kind and wise blue tender engine. He likes to share and help other engines. His rival is Gordon. He has an girlfriend named Belle.
- Henry - A well-mannered green tender engine. He likes Gordon and James. His rival is Spamcan. He has an girlfriend named Madge.
- Gordon - A important blue express tender engine. He likes to pull express trains. He is an rival to Edward. His rival is Old Stuck Up. And his haft-brother is Spencer. He has an girlfriend named Elizabeth
- James - A vain red tender engine. He hates tank engines especially Thomas, and belives he's better than all of them. He is an rival to Thomas. His rival is Duncan. And his haft-brother is Diesel. He has an girlfriend named Molly.
- Percy - Thomas' best friend. He likes to play jokes on other engines. His rival is Bulgy. He has an girlfriend named Rosie.
- Toby - An old steam tram. He is square and his body is made out of wood. His rival is The Diesel D261. He has a girlfriend named Flora. And he also has two coaches named Henriatta and Victoria.
- Duck - A GWR Pannier tank engine who works hard, pulling coaches and frieght cars. His rivals are Diesel and Diesel 10. He has an girlfriend named Daisy, the Diesel Rail-Car. And he also has two coaches named Alice and Mirabel.
- Donald & Douglas - The Scottish Twin Engines. They like to pull frieght trains and coaches. Their rivals are Arry and Bert. They have two girlfriends named Pip and Emma.
- Oliver - The GWR Tank Engine, who is Duck's best friend. His rival is Duncan. He has two coaches named Isabel and Dulcie. And he also has a girlfriend named Lady.
- Emily - A Stirling Single tender engine, who is beautiful. She is Thomas' girlfriend. Her rival is The Diesel D261. She has two green coaches named Martha and Jennifer.
- Molly - A yellow tender engine. She is James' girlfriend. Her rival is Diesel 10.
- Eagle - James' older brother. He is wise and helpful. His rival is Gordon.
- Kenny - A orange troublesome saddletank engine, who has a lot of back luck. He often gets into accidents by falling off cliffs and bridges, and being tossed up by the other engines. James teases him for his bad luck. Kenny's rival is James..
Other Steam Engines
- Bill and Ben - Two naughty tank engine twins.
- Stepney - The bluebell engine. His best friends are Oliver and Duck. His rivals are Class 40, Spencer and Duncan.
- Harvey - The crane engine.
- Arthur - The LMS Engine. Great friends with Thomas and Duck.
- Murdoch - A big and strong orange engine who tends to be queit.
- Spencer - The big silver engine and the private engine of the Duke & Duchess of Boxford.
- Wilbert - A friendly blue saddletank engine.
- Neville - A black steamie with a square body like a diesel.
- Rosie - Percy's girlfriend.
- Billy - A silly orange engine and Stanley and Charlie's younger brother.
- Hank - An American engine.
- Flora - Toby's girlfriend.
- Hiro - A japanese engine. Who is known for being "Master of the Railway". He has a love/hate relationship with Spencer. His best friend is Thomas. His enemies are Sixteen, Arry and Bert.
- Victor - The engine in charge of the steamworks.
- Whiff - The garbage engine.
- Stanley - A little silver engine and Charlie and Billy's older brother. He is friends with Duck.
- Charlie - Billy's older brother and Stanley's younger brother.
- Fergus - A railway traction engine.
- Lady - A beautiful gold tank engine and Oliver's girlfriend.
- Mallard - Gordon and Spencer's cousin. He can be vain at times, just like James. But when engines work with him more, they see just how really useful Mallard is.
Misty Island Logging Locos
- Bash & Dash - Fun loving twin steam engines who finish each others sentences.
- Ferdinand - A gentle giant. He has a catch phrase which is "That's Right!"
Other Railway Engines
- Alfred - A Loaned B12 who hates Henry being the real Number 3. In "End of the Rails", he died during an accident down a hill and off grassy mountain cliff and down the bottom. He was scrapped after that.
Diesel Engines
- Diesel - The other main villian of the series. He is James' haft-brother. Diesel always hates getting his airtake messed up.
- Diesel 10 - A diesel with a claw.
- Daisy - The only female villian in the series. She is friends with James and Diesel.
- Mavis - The quarry diesel engine. She gets along with both the steamies and the diesels.
- Class 40 - A very bad diesel.
- Arry & Bert - The scrapyard diesels.
- Salty - The dockside diesel.
- Dennis - A lazy diesel.
- BoCo - A big green friendly diesel.
- Bear-A friendly diesel engine who helps Boco pull the express while Gordon, Henry, James, or Donald, and Douglas are away.
- Den -
- Dart -
- Sidney -
- Norman -
- Paxton -
Narrow Gauge Engines
- Skarloey - The number 1 engine.
- Rheneas - Skarloey's best friend.
- Sir Handel - The wise and kind engine.
- Peter Sam - The kind engine.
- Rusty - The hard working diesel engine.
- Duncan - James' Narrow Gauge friend. He always hates Skarloey.
- Freddie - The old mountain engine.
- Duke - The oldest engine.
- Bertrum - The helpful engine. He is friends with Skarloey, Rheneas, Rusty, Duncan and Peter Sam.
- Smudger - The troublesome engine. He is Duncan's haft-brother.
Human Characters
- Sir Topham Hatt
- Lady Hatt
- Mr. Percival
Other Characters
- Barney - Thomas' driver.
- Stan Marsh - Thomas' fireman.
- Riff - Edward's driver.
- Chef - Edward's fireman
- Diddy Kong - Henry's driver
- Mr. Garrison - Henry's fireman
- Donkey Kong - Gordon's driver
- Randy Marsh - Gordon's fireman
- BJ - James' driver.
- Eric Cartman - James' fireman
- Lenny - Percy's driver
- Gary - Percy's fireman
- Toad - Toby's driver
- Ned Flanders - Duck's driver.
- Kyle Broflovski - Duck's fireman.
- Terence - Donald's Driver.
- Tom - Donald's Driver.
- Phillip - Douglas' Driver.
- Mr. Krabs - Douglas' Fireman.
- Jeff - Oliver's Driver
- Kenny McCormick - Oliver's Fireman
- Baby Bop - Emily's driver.
- Wendy Testaburger - Emily's fireman.
- Mr. Smithers - Stepney's driver
- Carl - Stepney's fireman
- Mr. Burns - Diesel's driver
- Shelia Broflovski - Daisy's driver
- Mr. Mackey - BoCo's driver
- Barney has his Season 3 voice and 1995 costume.
- Baby Bop has hee Season 3 voice and 1996 costume.
- BJ has his Season 3 voice and 1996 costume.
- Riff has his Season 10 voice and 2006 costume.
- All coaches have faces, unlike the TV series.
- Season 1 (Episodes 1-20)
- Season 2 (Episodees 21-40)
- Season 3 (Episodes 41-61)