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|September 6, 2000
Volume 2, Issue 36
|Midwifery Today E-News
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This issue of Midwifery Today E-News is sponsored by:
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In This Week's Issue:
1) Quote of the Week
1) Quote of the Week:
"I honour the process of birth as natural and instinctual, relying on the 'forces of nature' and the use of practical, non-intervening skills to facilitate this passage."
- Diane Smith, midwife
2) The Art of Midwifery
If you have a "bleeder" from a tear that you can see, try direct pressure with a sterile gauze pad on which you have placed Yunan Paiyu, A Chinese herbal combination in capsule form. Three applications of one capsule each emptied on the gauze pad worked well for me over a twenty minute period. The tear actually looked cauterized!
- Donna Vidam, Midwifery Today Issue 49
Share your midwifery arts with E-News readers! Send your favorite tricks to firstname.lastname@example.com
3) News Flashes
Cranberry juice can prevent cystitis and other urinary tract infections from occurring because cranberries contain isolated compounds called condensed tannins or proanthocyanidins, according to a recent study. These compounds are capable of preventing Esherician coli (E coli) from attaching to cells in the urinary tract. One of the researchers on the State University of New Jersey team that led the study estimates that a 300 ml glass of high-concentration cranberry juice drink consumed daily would help prevent E coli urine infections. -Pro-fessional Care of Mother & Child, Vol. 10, No. 1
DOCTORS ARE THE THIRD LEADING CAUSE OF DEATH IN THE US, Causing 250,000 Deaths Every YEAR. Seems hard to believe, but the most widely circulated medical periodical in the world, JAMA, published this information last month. Read all the details at www.mercola.com and learn how you can protect yourself and your family from their actions.
4) Cytotec
While the United States has a system in place to insure that all drugs must be evaluated by the FDA before they are allowed on the market and that certain drugs are to be dispensed only through physician prescription, there is a hole in this system. Once a drug has been approved by the FDA for one use and put on the market, there is nothing to prevent a physician from using that drug for whatever use at any dose. Trials of new uses of drugs are important as long as the trials are done as research and everyone understands that this use is experimental with informed consent from the patient. Misoprostol induction shows potential for certain benefits but these benefits must be documented by careful research which, at the same time, looks carefully for the risks.
We can't just throw drugs at people in an uncontrolled way. If a practitioner hears about a new use and simply starts using the drug this new way, this is experimenting on patients without the usual safeguards in place for research subjects. And while practitioners should report to the FDA on such off label trials and should always report to the FDA on side effects and risks found, in reality only a very small number of practitioners ever report anything to the FDA. As a result, a large information vacuum exists in the United States with regard to what prescription drugs are being used for which purposes and what side effects and serious risks have occurred. So when practitioners simply begin to use a drug for a new purpose, there follows a phenomenon I have experienced for years as a practicing clinician but rarely see described in print--the informal spread of clinical experience. In hospital corridors, lunchrooms and staff lounges, doctors, midwives and nurses share their ideas and experience.
A recent technology makes it possible to listen in on such clinical chat--online web pages and chat rooms. By accessing the World Wide Web and then using key words such as "misoprostol" and "pregnancy," many web pages and chat lines appear. Clinicians, scientists, policy makers and patients should read these Internet pages from time to time. While clinicians writing on the web are not necessarily representative of all clinicians, it is possible to discover how at least some of today's clinicians think and act. It seems like eavesdropping because of their candor and their blunt way of expressing ideas and opinions and revealing their attitudes. It is the informal communication of uncontrolled clinical experience which has driven the spread of misoprostol induction as is apparent from the following actual statements taken from the Internet in 1998: (2)
"Cytotec is extremely effective at very low doses, is very cheap, and has been used on many, many women without their being aware that it really is still an experimental use."
"I must say that I have heard some great things about Cytotec myself. I know some people who have used it and say that they have pretty good luck with it. It sounds like your ladies are pretty happy with its effects--two-hour labors and such. Just be careful. I would have to say that the biggest danger is leaving the woman alone. The stuff turns the cervix to complete MUSHIE (web message emphasis, not mine) and opens it with a couple of contractions. So whatever you do, remember that you must not stay gone too long."
"At my suggestion our high risk OB referral hospital tried Cytotec--one-half tab per vagina--and after two cases of hyperstimulation stopped its use."
"We've seen no cases of hyperstimulation after Cytotec that did not respond to a two-gram bolus of MgSo4. You can almost count on a delivery twelve hours after inserting the Cytotec tablet."
"We are using it at Yale and although there is a format for how to give it, there is still controversy on to whom to give it. Pharmacy uses one of their nifty little pill cutters and sends us one-fourth of a 100 microgram tablet (remember this stuff was made for treatment of ulcers!)"
"We are using misoprostol regularly for induction--my department loves it. We use one of the protocols published on OBGYN.Net web page."
"Our biggest fear is that the company will pull Cytotec from the market, since our internist/GI buddies tell us that it isn't worth a darn for its labeled indication."
What is apparent from this Internet medical practice is the lack of appreciation of any borderline between experimenting on patients and practicing medicine on patients and the absence of concern for patient's rights to informed consent.
Also apparent from reading the Internet is the inability of many
clinicians to critically review published papers. The general
assumption is that since there are, as stated in one web message
"gobs of references" (2), the scientific work has been done and it is
okay to use this drug for this purpose. The tendency for clinicians
to misinterpret scientific papers is in part because of a difference
in approach since scientists must believe they don't know while
clinicians, in order to do what they do, must believe they do know. A
common attitude among clinicians, revealed by Internet messages, is
that pregnancy and birth are dangerous until proven safe while
technology and drugs are safe until proven dangerous. -Marsden Wagner, MD, Misoprostol (Cytotec) for Labor Induction: A Cautionary
Tale. Read the entire article on the Midwifery Today website:
The June 1999 issue of the American Journal of Obstetrics and Gynecology published the article "Uterine rupture associated with the use of misoprostol in the gravid patient with a previous cesarean section." The data in this article are truly frightening. "Uterine rupture occurred in 5 of 89 patients with previous cesarean delivery who had labor induced with misoprostol. The uterine rupture rate for patients attempting vaginal birth after cesarean was significantly higher in those who received misoprostol, 5.6 percent, than in those who did not, 0.2 percent or 1 in 423, p=0.0001)." Furthermore, a medical records review turned up several more cases of uterine rupture associated with using Cytotec with VBAC not included in their calculations.
Be clear on what this says. Over five percent of women given Cytotec for VBAC had a ruptured uterus, a 28-fold increase over those who did not have Cytotec induction for VBAC. This is a truly shocking rate of uterine rupture. And one of the five women with uterine rupture ended up with a dead baby as a result of the rupture.
Just in case you think this paper reports an aberration, the same issue of this journal has a second paper in which three of eighty-one women receiving Cytotec for a VBAC had uterine rupture--a still shocking rate of 3.7 percent. And one of the three babies died in the NICU after the rupture. Both these papers were retrospective which means that none of the women given Cytotec were part of a research project. Thus, none had received the protection of research subjects, including information on the experimental nature of the drug given to them. So in these two papers, of 170 women given Cytotec for induction with VBAC, eight have lost their uterus and two lost a baby as well. It is my educated guess that to this day none of them has been told that they were given a drug for a purpose not approved by the FDA nor has been told their case is described in published papers saying this drug should not be used in this way.
These women and babies paid a very big price because their practitioners were willing to use a very powerful drug before it has been approved by the FDA for this purpose and before it was adequately evaluated by prospective, controlled research. Hopefully, no midwife will ever be involved in any birth where Cytotec is used for VBAC and all midwives will do everything possible to prevent the use of Cytotec for any type of induction until we have more complete evaluation.
- Marsden Wagner MD, MSPH
When uterine overactivity occurs [due to artificial means], an attempt must be made to remove the drug that is causing the problem. Turning off an oxytocin infusion is fast and easy, and usually results in a rapid return to more normal uterine activity. Some dinoprostone products are made with a string and are easy to remove quickly. When dinoprostone gel is used, attempts can be made to flush it from the vagina with sterile saline-clearly a slower and less effective procedure. With misoprostol, attempts can be made to remove the pill, if it has not yet been absorbed. More often than not, the pill has already been completely absorbed. In this case, there is no choice but to ride out the excessive contraction pattern with careful monitoring and measures to maximize the supply of oxygen to the fetus.
- Jennifer Enoch, Midwifery today Issue 49
Midwifery Today Issue 49 discusses at length the use of misoprostol
(cytotec). To order the issue, go to:
E-News readers talk about Cytotec:
A primagravida mom went a week postdates and her doctor wanted to induce labor. He admitted her at 9 pm, and started Cytotec at 9:45. At 1:45 she was checked, and no change was noted, so another dose was inserted. At 6 pm she was contracting mildly, about 7 mins apart. At her next vag check, she was found to be 2-3 cms and 80% effaced, which was great progress from 0 dilation and no effacement at all. I'm told by her there was no cervical discomfort with Cytotec, and no pain or cramping that she noticed. Other clients who have induced using Cervadil and Progestagel have complained of burning at the cervix and intense cramping from use. From this I would ascertain that Cytotec seems to be equally useful as an induction agent, but seems to be less uncomfortable for the moms. Has anyone else come to this conclusion? I would love to hear your stories.
- Gina Acosta,ICCE,CD,
I can only provide insight from the patient's perspective as I have not used Cytotec in my clinical setting. Each of my pregnancies have been complicated by pregnancy-induced hypertension. With my fourth and most recent birth on August 4, I was induced at 38 weeks for PIH as my blood pressures on bedrest were 160s/100s (in labor they were as high as 200/100 and I got a dose of Apresoline). I had headaches for several days that wouldn't resolve with analgesia. I put off induction for a week, against the advice of two OBs and a perinatologist. Before the day I was induced, I was feeling well and had a Bishop's score of 5. I decided to go ahead with it as I just didn't have the same feeling of well-being that I had had in previous weeks. Something just wasn't right. I had a Bishop's score of 8 on the day I was induced and my baby's head was ballotable.
I had been induced with Pitocin twice before, once for PIH and once for severe preeclampsia. I opted to try Cytotec this time so that I could be more mobile and use hydrotherapy. After getting us settled in, my labor nurse inserted a 50 microgram tablet of Cytotec vaginally. In no time at all I was contracting every 1-2 minutes. Compared to Pitocin, my contractions didn't peak as fast with Cytotec and I felt I could cope with the discomfort better. I felt so tied down with Pitocin and felt more in control this time because I wasn't stuck in bed on my left side. I'm glad I had Cytotec as an induction option for this birth.
- Maurenne Griese, RNC, BSN, CCE, CBE
When it was introduced at my hospital I did my own research and found many reasons not to use Cytotec at the dosage we use (100 mcg PO) but was told I either give it or quit. About two years later the research is still saying a lower dose is better as it doesn't carry the risk of hyperstimulation and is just as effective. Clinically, I must say I haven't seen the problems I had expected and it has proven to be much more effective than any other methods tried. One big advantage is the intermittent monitoring so women can be out of bed, walk, enjoy the tub, etc. Because it is so cheap and easily obtainable I worry that it may be used out of the hospital. A friend of mine was given a few doses of Cytotec to be used for a clinic birth, suffered hyperstimulation, and the baby was born with a 0 Apgar, severely brain damaged and is unlikely to survive for long. Use EXTREME caution when using Cytotec!
- Valerie G., RNC, CD
I am a CNM in an out-of-hospital (OOH) birth practice and I will admit to using Cytotec RARELY in the past few years. I am very well informed about the risk and benefits of Cytotec and that I can appropriately offer it to a RARE client for whom indications exist for getting labor going. I tend to resent the attitude of midwife purists who believe that, as an OOH birth midwife, I should only be catching babies that fall into my hands out of the lowest-risk moms--no interventions allowed. The idea, apparently, is that if a client is high enough risk to need Cytotec induction, she is too high risk for an OOH birth anyway.
This might be true in some cases and we OOH midwives need to remain sensible with our risk assessment, but there are certainly other cases in which the woman's risk is low, but clearly increasing with time. If we sit on our hands and wait indefinitely for labor, her risk continues to increase and she may well find herself in an interventive hospital birth situation, whereas if we push her into labor now, she will deliver OOH as a low-risk person.
Case in point: a 29-year-old motivated healthy G3P2 with a history of PIH in her first pregnancy (induced in the hospital at 42+ weeks), no PIH with second pregnancy (fast and easy homebirth at 42 weeks), developing PIH in the current pregnancy. She is extremely desirous of another homebirth, very adverse to hospital birth. Motivated and healthy, she eats a high-protein diet, rests on her left side at prescribed intervals, takes her cal/mag supplement, monitors her BP at home in-between visits. She does everything she can do to remain low-risk, but her BP is clearly climbing, from 112/72 in mid-pregnancy to 130/80 at 32 weeks to 140/84 at 36 weeks to 142/90 at 39 weeks to 150/92 at 40 weeks. She has no swelling or excessive weight gain, DTRs are WNL, her cervix is 3 cm, EFW is 8-1/2 pounds. Her history of two previous 42 week pregnancies would suggest that this kid probably planning to come out soon, but her BP is not one that you'd want to watch rising for another 2 weeks. She doesn't have fulminating preeclampsia, obviously, but her risk is clearly increasing with her BP.
She tries herbs, homeopathics, nipple stim, lovemaking, etc., and finally, after a long discussion of risks and benefits (and signing a consent form), we bring her into labor slowly with two small doses of Cytotec. Her healthy baby boy (8lbs 6 oz) is born easily at home that evening. Was it inappropriate to use the Cytotec in this case? I'm a nurse practitioner with prescriptive privileges, so it is within my professional authority to prescribe. It's legal, but is it good midwifery? Should I have allowed her to become more hypertensive, leading to increased risk for her and her baby and possibly an interventive hospital birth? Not in my mind.
If Cytotec is becoming the candy of the OOH birth midwife as people are reporting, we're in big trouble because women are going to get hurt (and midwifery will get hurt as well). But we don't need to throw the baby out with the bathwater. Clear indications for induction, extensive informed consent, extremely cautious dosing (max of two widely-spaced tiny doses in any day), and careful OOH monitoring need to be a part of any appropriate use of Cytotec OOH.
- Anon.
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Nacer en Casa, First International Congress of Home Delivery and Childbirth
October 20-22, 2000, Jerez de la Frontera, Cadiz, Spain.
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Marsden Wagner, Michel Odent, and many midwives and practitioners
from Spain, Germany, Denmark, the Netherlands. Program and
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Cytotec, continued
Cytotec can be very useful in midwifery but it needs to be used with prudence. There doesn't seem to be common ground on what the dosage should be. Because it was never meant to be used on pregnant women, safe dosages have not been established. From my experience, you need very little--17-20 micrograms to start. It can be smeared on the cervix in situations where the woman has spontaneous PROM, she is postdates with a very large baby, or is exhibiting other signs of needing to have her baby.
Cytotec works differently on different women. Some need very little in their system, while others need several doses. Never administer more than 50 micrograms at a time, and that as a general rule is too much. Just because a woman is obese does not justify a large dose; her cervix is still the same size. Contractions are very fast and close together without giving the baby or mom a chance to recover. Generally, I would say 89 percent of babies birthed with Cytotec induction suffer some degree of respiratory distress. Another side effect is that moms bleed, if not a major hemorrhage, the cervix will bleed because it has had to dilate so fast. I've seen Cytotec erase swollen anterior cervical lips.
Most midwives will not be comfortable using Cytotec because there is so much we do not know or understand about it and it was never designated for obstetrical use. However, I feel if it is used with prudence, it can be a very valuable tool in our birth bag. I believe that in the hospitals Cytotec is being used too frequently and at too high a dose. Its use with VBACS is totally contraindicated. We must remember that it cannot be turned off, up or down like Pitocin. Once it gets into the system, it takes several hours to clear out. As midwives we need to learn patience and watch and wait. Cytotec should never be used for our own convenience, or to induce a woman who is tired of being pregnant. It should be saved for rare situations, and treated with the utmost respect.
- Cathy O'Bryant, CPM
With recent articles in several midwifery publications regarding the risks associated with the use of Cytotec for inducing labor, and reports that Cytotec is the induction agent of choice in many hospitals, readers may be interested in this memo. The manufacturer is finally taking a stand on the off-label use of this drug.
- Susan Hodges
Dear Health Care Provider:
The uterotonic effect of Cytotec is an inherent property of prostaglandin E1(PGE1), of which Cytotec is stable, orally active, synthetic analog. Searle has become aware of some instances where Cytotec, outside of its approved indication, was used as a cervical ripening agent prior to termination of pregnancy, or for induction of labor, in spite of the specific contraindications to its use during pregnancy.
Serious adverse events reported following off-label use of Cytotec in pregnant women include maternal or fetal death; uterine hyperstimulation, rupture or perforation requiring uterine surgical repair, hysterectomy orsalpingo-oophorectomy; amniotic fluid embolism; severe vaginal bleeding, retained placenta, shock, fetal bradycardia and pelvic pain.
Searle has not conducted research concerning the use of Cytotec for cervical ripening prior to termination of pregnancy or for induction of labor, nor does Searle intend to study or support these uses. Therefore, Searle is unable to provide complete risk information for Cytotec when it is used for such purposes. In addition to the known and unknown acute risks to the mother and fetus, the effect of Cytotec on the later growth, development and functional maturation of the child when Cytotec is used for induction of labor or cervical ripening has not been established.
Searle promotes the use of Cytotec only for its approved indication. Please read the enclosed updated complete Prescribing Information for Cytotec. Further information may be obtained by calling 1-800-323-4204.
Michael Cullen, MD
5) Check It Out!
EUGENE, OREGON MIDWIFERY TODAY CONFERENCE program is online on the
Midwifery Today web site. Come meet with us in our home town!
BIRTH AT SEA, a poem by Holly Knight
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6) Midwifery Today's Online Forum
"I want to start a movement that asks state legislatures and the federal government to mandate that insurance companies pay for homebirth. If they can make insurance companies pay for birth control which is considered a "reproductive right," then homebirth should also be a reproductive right.
Besides, it will save the insurance companies money for every homebirth. Do you think this could happen?"
To respond: Go to: our forums. Click on "Legal Battles and Birth Politics."
7) Question of the Week
Is perineal massage necessary? Does it help or hinder tearing? I have been trained to do perineal massage and it seems to me that all it does is make the tissues edematous. I'm beginning to think that hot compresses and oil as well as positioning may be enough.
- Karen
Send your responses to email@example.com
8) Question of the Week Responses
Q: A friend recently had a late miscarriage (18 wks) due to a partial septum in her uterus. She is now considering surgery to remove the septum, and wonders whether the risks/complications and success rate of such surgery would make it a better choice than simply continuing to try to carry a foetus to term (she realizes she may have to endure many miscarriages if she chooses the latter). Does anyone have any experience with this kind of surgery?
- Jennifer Landels, BA, CBE
A: I had a uterine septum. My first pregnancy ended at 35 weeks with a vaginal breech birth. My second pregnancy went to 31 weeks (following 3 days of tocolytics in hospital), c-section for footling breech, and the baby (now 8 yrs old and strong as a horse) spent 3 1/2 weeks in the NICU. I had outpatient hysteroscopic septaplasty (laparoscopically assisted, and under general anesthesia) in anticipation of my third pregnancy, conceived after waiting three normal menstrual cycles for healing (was given estrogen to take after the surgery for a couple weeks to facilitate this process), and went to 38 1/2 weeks. Ultrasound during that pregnancy could still "see" vestiges of the septal remains. We had a lovely vertex homebirth! The baby didn't commit to being head down until 36 weeks. Now I am 30 weeks along with a TWIN pregnancy! Ultrasound shows no sign of the septum, and the babies both change presentation on a daily basis. So, based on my personal experience, I can say that depending on the results of your hysterosalpingogram, the results are DEFINITELY worth it! In my case the septum was not vascular tissue, so there is no intrauterine scarring from the procedure. The defect was not palpable externally, and I never knew about it until I was well into my first pregnancy when I was 27 years old.
I will note that with our homebirth we had a 65 minute (but otherwise uncomplicated) third stage, and the placenta had been implanted along the former septal site, which was still apparently non-vascular, as that area of the placenta was composed of cartilaginous-type tissue and no vascular area.
- Jennifer Seymour, CNM
9) Question of the Quarter for Midwifery Today magazine
Who is in your birth community? What does the concept "birth community" mean to you? How have you or how would you go about organizing one? Send us your favorite story about your birth community.
Please submit your response by September 15, 2000 to:
10) For Coming E-News Themes
1. Choose a favorite herb or two from your birth bag and share a use
or two. Be specific about amounts, dosages, frequency, duration. Or
tell a brief story as an example of its effectiveness!
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Know a strong woman? Helping empower one? If you haven't already done so, please forward this issue of Midwifery Today E-News to one or two of your friends or business associates. Thanks so much!
11) Switchboard
More on rhogam [Issue 2:35]:
Iserve a large Amish community. One of my clients is an only and oldest child, an extreme rarity in the Amish community. Her mother and father buried six children due to Rh sensitization. Their oldest daughter, Rosie, was born on the eve of the availability of Rhogam in the 60s. I have listened for many hours to stories about the other babies, and the lengths that Rosie's mom went to, to ensure living children. She traveled to the tertiary care children's hospital, had many many amniocentesis, and would tell me how black the fluid was, how the doctors would shake their heads, and how she knew yet another baby was to die, either in utero or shortly after birth.
I can't imagine how hard it was for Rosie to grow up under the umbrella of all that grief, yearning, and dashed hopes. It is hard to be an only child in the Amish community because most socialization is done with sisters. Most Amish women do not have close female friends the way their non-Amish counterparts do. She lives with her mother and father, husband and her children, and is isolated and lonely. She has no one except her very immediate family to share her concerns, joys, and fears.
Her mother seems to be chronically depressed, and is on medication. Rosie underwent very serious depression during her last birth with me, barely able to get out of bed, and ended up on Prozac before the baby was born.
Most of my Amish clients ask for 28 week rhogam because they have received it from the doctors in previous pregnancies. Most of them know the risks of sensitization and do not want to take any chances. There are many genetic diseases in the Amish community that cannot be prevented, but this condition can be prevented and they are very willing to pay the price for the rhogam shot, and I am very willing to come to their homes and give it to them.
Most of my clients know most Rhogam is probably unnecessary, but the price is extreme if sensitization occur, and it is not one I am willing to pay or to suggest to my clients.
- Jennifer Williams, CPM
I am negative and have had Rhogam or anti-D after four births. I don't like having it but I did "just in case." I have since found out that a test within the first 48 hours after a birth shows if there is any transfer of baby's blood across. This would save having Rhogam if there is no blood transfer and also give women time to have it if there is.
- Colita
I have found that postpartum depression (PPD) is almost always related to low thyroid function after a birth. All the hormone levels take a dip after birth and then most come back up to a non-pregnant normal state. But the thyroid often stays depressed. If asked, women with PPD often admit to additional symptoms of dry skin, brittle hair, chocolate cravings, poor night vision, inability to loose weight after birth, fuzzy thinking, and tiredness as well as the depression.
I often find that giving Thytrophin PMG and Iodomere from Standard Process Labs is sufficient to pull them out of postpartum depression. I prefer to stay away from straight kelp at that point because it can flavor the milk and turn baby away from nursing. The Thytrophin PMG helps induce the thyroid to work normally again. Sometimes I end up sending women to an endocrinologist for thyroid balancing. We have a local one who has actually done research on the connection between postpartum depression and low thyroid. Many of them do not understand the connection. If women go to a GP, he will often only check the simple thyroid hormone level and it will be low normal, so they do not check further. You need to run all the thyroid tests to find the problem. Most GPs will simply put the mother on an antidepressant for years to come. To me that is tragic.
- J. Jones, CPM
I would be very grateful for any advice, tips etc. of how to come to some peace over a disappointing birth. I have some ideas myself, but would be grateful for more! This is not sadness over things that had to change for the health of the baby, but things that were and were not done which were on my birth plan and were pre-agreed, and could easily have been done without upset or hindrance to the birth, the baby or myelf.
- Anon.
12) Classified Advertising
Southern Oregon Midwifery Conference, October 7&8. Midwives, Doctors, Naturopaths. Featuring Anne Frye. Info: (541) 488-4260.
This publication is presented by Midwifery Today, Inc., for the sole purpose of disseminating general health information for public benefit. The information contained in or provided through this publication is intended for general consumer understanding and education only and is not intended to be, and is not provided as, a substitute for professional medical advice, diagnosis or treatment.
Midwifery Today, Inc., does not assume liability for the use of this information in any jurisdiction or for the contents of any external Internet sites referenced, nor does it endorse any commercial product or service mentioned or advertised in this publication. Always seek the advice of your midwife, physician, nurse or other qualified health care provider before you undergo any treatment or for answers to any questions you may have regarding any medical condition.
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- Resident, Plastic Surgery, 1988-1991, Baylor College of Medicine, Houston, TX
- Resident, General Surgery, 1985-1988, The University of Texas Health Science Center, Houston, Texas
- M.D., Cum Laude, AOA, 1981-1985, Baylor College of Medicine, Houston, Texas
- B.A., Cum Laude, 1974-1977, Duke University, Durham, North Carolina
- American Board of Plastic Surgery 1996
- American Society of Plastic Surgeons
- Texas Medical Society
- Society of Surgical Oncologist
- Houston Society of Plastic Surgeons
- Texas Society of Plastic Surgeons
- The American Society for Aesthetic Plastic Surgery
- The American Society of Plastic and Reconstructive Surgeons
- Cancer Forward: The Foundation for Cancer Survivors

subset: commoncrawl


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Welcome to Humphreys County, Tennessee, a county rich in history,natural resources, industry and family entertainment. "The Land of Three Rivers" offers the natural beauty of the Tennessee River, the Duck River and the Buffalo River. Taking advantage of the friendly, hometown atmosphere, visitors travel from all over the country to enjoy boating, fishing, camping and a variety of other recreational activities.
The middle Tennessee area is easily accessible from Interstate 40, Exit 143, which accesses Hwy. 13 and leads north to the county seat of Waverly. U.S. Highway 70 runs through the three major cities in the county. Waverly, the largest city and center of the county is flanked on the east by McEwen, which is rich in Irish heritage, and New Johnsonville on the west, which is rich in Civil War history.
One of Humphreys County's largest attractions is Loretta Lynn's Ranch and Family Campground near Hurricane Mills. Visitors are allowed a glimpse into the personal life of country music legend, Loretta Lynn, with family entertainment from April through November of each year. The museum and gift shop depict various aspects of Lynn's life. The ranch also sponsors the AMA National Motocross Championship as well as concerts, trail rides and other activities throughout the year.
The city of Waverly is host to "Music on the Square" every Saturday night during the summer months. This lively entertainment event features different performers each week and is free to the public.
In McEwen, St. Patrick's Irish Picnic and Homecoming, held the last Friday and Saturday in July, is one of the world's largest outdoor barbeque events. Drawing thousands of visitors each year, St. Patrick's famous barbequed pork, chickens, sauce and fixings keep visitors coming back for more.
Ready access to transportation via railroad, waterways, highways and interstates has facilitated the growth of several types of industry in Humphreys County. A small airport, located in Waverly, serves private aircraft.
Blue Creek Nature Center, located just outside Waverly and the Tennessee National Wildlife Refuge, which runs along Duck River, encompasses more than 52,000 acres and is perfect for observing a look at untouched wildlife. The peaceful blue waters and many marinas make these popular getaways for the entire family. Avid fishermen and hunters find a paradise along the refuge with organized hunts and fishing tournaments.
Humphreys County is rich in history with Civil War artifacts, antebellum homes and more. The Johnsonville Historic State Park, Humphreys County Museum and Civil War Fort, Nolan House, McAdoo House, Enoch's Mill and one of only two old Greyhound bus stations found in the state offer a backward glance into the history of Humphreys County.
The following pages and sites offer further information on the resources found in Humphreys County, the heart of the "Volunteer State".
Federal Fair Housing
(Click to Enlarge)
Hurricane Mills Dam at
Loretta Lynn Ranch
Humphreys County Chamber of Commerce is supported by many area businesses and individuals.
Home | Message from the County Executive | Economic Development | County Offices | Education | Healthcare


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Cancer. Dead honey bees. Poisoned bobcats. These are all related to systemic pesticides in our food, our air, our rivers and our soil.
That is what in the scientific world, or what my chemistry professors in college would call, a working hypothesis: The use of pesticides, fungicides and rodenticides by industry and households are harming animals and people by working their way into the ecosystems and food sources.
First, scientists have shown a connection to a pesticide the chemical industry has said is benign with honey bee kills. They are called neonicotinoids and you can go to Youtube to listen to The Organic View, a radio show's interview with Dr. Alex Lu of Harvard talk about the connection between such pesticides and honey bee deaths. Lu also is studying aggregate levels of neonicotinoids in children (http://www.youtube.com/watch?v=gX2UPExSOV0).
This week, the U.S. Environmental Protection Agency put out new warning labels on products containing neonicotinoids. "This product can kill bees and other insect pollinators," reads the label in bold red type. The label also contains a "bee hazard icon," a honey bee encapsulated in a red diamond, to alert users to the product's deadly effect on bees and other pollinators.
If it were up to me, I would not use any product with the bee hazard warning label. However, the EPA label (http://www.epa.gov/pesticides/ecosystem/pollinator/bee-label-info-graphic.pdf) offers restrictions if you must:
• Don't spray a plant when bees are present. Don't apply pesticides until all the petals have fallen off.
• Don't spray when there's even the slightest chance of pesticide drift. Wind can take even a small amount of pesticides to other areas. Drift has resulted in bee kills, the label says.
• Bees can die from direct contact AND from ingestion of residues in nectar and pollen when the pesticide is applied as a seed treatment, put into the soil, as a tree injection or a foliar. In short, the stuff can kill bees weeks later, when the bees feed on the nectar.
This last warning reminds me of the secondary exposures to rodenticides that are killing wildlife in Southern California.
In stories I've written over the past six weeks, scientists from the U.S. Geological Survey and UCLA have found links between rat poison and dead bobcats. This link has also been documented with other wildlife. Though complex, scientists believe the rodenticides put out by homeowners or institutions enter the food chain through rats, squirrels and possums. Raptors, bobcats and mountain lions feed on these contaminated animals and the poison enters their systems, showing up as an auto-immune disease. The cats get so weak they die of mange, an ordinary skin disease.
When I ran into San Dimas City Councilman Denis Bertone, who heads the San Gabriel Valley Council of Governments environment committee, he told me he copied all my bobcat/rodenticide stories and sent them to individual members of the City Council. I hope all cities pass an ordinance banning use of rodenticides in the outdoors.
The folks at Poison Free Malibu sent me a link (http://www.cdpr.ca.gov/docs/legbills/rulepkgs/13-002/13-002.htm) from the California Department of Pesticide Regulation. The CDPR is proposing new restrictions on brodifacoum, bromadiolone, difenacoum and difethialone, "second generation anticoagulant rodenticide products. You can email comments on the proposed regulation to email@example.com. or send by fax at 916-324-1452. The deadline is Oct. 4.
It makes sense to limit pesticide use — for preserving wildlife and our own lives.
Steve Scauzillo covers transportation and the environment for the Los Angeles News Group. He's the current recipient of the Aldo Leopold Award for Distinguished Editorial Writing from The Wilderness Society. Follow him on Twitter @stevscaz or email him at firstname.lastname@example.com.


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The New School
Mannes Ensemble-in-Residence, The Orion String Quartet Concert 4
Mannes Ensemble-In-Residence, The Orion String Quartet, offers four free concerts each year at Mannes. The Orion String Quartet is one of the most sought-after ensembles in the United States. Since its inception, the quartet has been consistently praised for the fresh perspective and individuality it brings to performances, offering diverse programs that juxtapose classic masterpieces with notable works by living composers. With over fifty performances each year, the members of the Orion String Quartet - violinists Daniel Phillips and Todd Phillips (brothers who share the first violin chair equally), violist Steven Tenenbom and cellist Timothy Eddy remain on the cutting edge of programming and serve as Artist Members of Chamber Music Society of Lincoln Center. The program for this concert will be announced here the week of the performance.
Benjamin Britten: Three Divertimenti
Wolfgang Amadeus Mozart: Quartet No. 23 in F Major, K 590
Robert Schumann: Quartet No. 1 in A minor, op. 41 no. 1
Mannes Concert Hall, Mannes Building, 150 West 85th Street
Pick up free tickets at Mannes on the day of the concert, starting at 6:00 p.m.
For more information call 212.580.0210 x4817
Email Updates
Browse Events by School


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A fire broke out at the apartments at 2100 S. State Street at Fircrest Drive early Monday morning, destroying four apartments, damaging eight others and leaving 51 people temporarily or permanently displaced.
According to Ukiah Fire Chief John Bartlett, firefighters from the now combined Ukiah and Ukiah Valley Fire Department were called to the scene along with Hopland Fire and Redwood Valley/Calpella Fire at around midnight Sunday. With the help of the Ukiah Police Department and Mendocino County Sheriff's Department, they evacuated 51 people. Forty of those people were taken to Ukiah High School for shelter and are being cared for by the Red Cross, while 11 others were taken with minor injuries to the Ukiah Valley Medical Center. No one was badly injured, Bartlett said.
Among the injuries were smoke inhalation and injuries caused when some people jumped out second story windows, blocked by the fire from safer exits. The cause of the fire is still unknown, Bartlett said. The buildings are still standing but four of the apartments, those most westerly in the complex, are a total loss. Eight others are livable but have smoke damage.
Evacuees came from throughout the complex, not just the damaged apartments. The complex has 50 units.


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Q. My bright nickel plating bath is giving me a lot of grief. Our problem is the lack of uniform brightness on the part. The side of the part directly facing the anode is bright in some cases but not others. If I attempt to plate multiple parts in the plating bath I get different shades of brightness on each of the parts. I performed a carbon treatment on the bath with no improvement in the results. Do you have any suggestions for how to resolve this problem? A.M.
A. Your nickel plating bath is due for a major checkup and overhaul. Your e-mail does not mention whether you have determined the concentration of the various components of the bath, but this would be the first step. As a second step, perform another carbon treatment on your plating bath and then replenish the required concentration of your brighteners.
You also do not mention whether your nickel plating bath is agitated. Modern plating technology requires that most plating baths must be agitated to ensure consistent concentrations throughout the bath.
Other things that you should consider are: temperature of the bath, chloride concentration and, most importantly, the cleanliness of the parts prior to plating.
I am e-mailing you a copy of the Nickel Tank Doctor to help you troubleshoot your nickel plating bath.


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From Margaret Dowd, President/CEO of the Lupus Research Institute
Dear S.L.E. Lupus Foundation Supporters,
As you may have seen in the news recently, most lupus patients in the United Kingdom may not be able to afford treatment with Benlysta® as a result of a recommendation by the National Institute for Health and Clinical Excellence (NICE). We at the S.L.E. Lupus Foundation along with our National Coalition of lupus patient groups fought hard to advocate for the approval of Benlysta by the U.S. Food and Drug Administration here in the United States; we are equally concerned that lupus patients everywhere have the same access to the best treatment available.
The approval of Benlysta as the first new treatment in 50 years was a source of renewed hope for the 1.5 Americans suffering with lupus, and we are proud to have helped bring that about. But we want to bring that same sense of hope to the millions of lupus patients throughout the world who might benefit from treatment.
Please take just a few minutes to CLICK HERE and add your voice to the thousands petitioning NICE to recommend that the United Kingdom's National Health Service provide coverage of Benlysta. Help us extend the loop against lupus all the way across the "pond!"
Thanks so much for your continued support,
Margaret Dowd
President/CEO Lupus Research Institute
Executive Director S.L.E. Lupus Foundation


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Components 101: Spokes
Spokes have three main functions:
- adding strength to the wheel rim – spokes connect the hub to the wheel rim and are held in tension (stretching force) causing the rim to be evenly pulled inwards. This arrangement makes the wheel extremely strong.
- transferring leg power from the hub to the wheel – enabling the force applied to the hub of the rear wheel by the chain and gears through the act of pedalling, to be carried efficiently.
- supporting rider weight on the wheel – by spreading the load so that it is more evenly distributed thus preventing too much stress on any single spoke.


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Korres Lip Butter Reviews
FLATTERING COLOR FOR EVERY WOMANI received this as part of a Korres kit from Sephora. I was struck by the sheer (bad pun intended) beauty of the shade. It is completely wearable and flattering for women of all complexions. It imparts a lovely (and comfortable) shine, with no tacky feel. — 4 years, 7 months agoGigiSD | 1102 reviews
This review is: Helpful | Not helpful | Inappropriate | 11 of 12 people said helpful
LovelyIt's wonderful; so creamy and moisturizing, The tints complement my lip tone well and it gives a nice shine. They're a bit expensive though. — 6 years, 6 months agovolta | 566 reviews
This review is: Helpful | Not helpful | Inappropriate | 5 of 7 people said helpful
KORRES NATURAL PRODUCTS LIP BUTTERI like this product but its not a HG. I got it in a Christmas kit with the shower gel and body butter. I love Korres so was curious to try their lip butters so I was happy to buy this in the kit. I use this by itself or as a primer under my lip stick for smoother application. If you put too much on you will get a white film but I don't have that problem as I use more sparingly. I wouldn't recommen...read mored this as a night treatment or something for severely chapped lips (Smiths rosebud salve is better for that). Its more something to put on when you don't want to look too "made up" and gives a gorgeous "your lips but better" look Pros: moisturizing, smooth, great colour and I love the pot Cons: Too expensive and I think I would like to see what else is out there before I would come back to this colour. I would try some of the other colours first. Overall? I love the product but its not my HG colour so I won't repurchase this colour but I am happy I have it. This lip butter smells more of coconut to me than guava. I really wanted to love this lip butter but it just didn't work for me. I think I would actually like it if it didn't leave a white film on my lips. I also think it should be called a lip balm rather than lip butter as it didn't feel all that creamy to me. I also bought quince and plum and the quince is much much more buttery. This balm moisturizes well unlike some other lip balms I've tried (Murad pomegranate lip treatment...). However, the name is misleading since it doesn't smell like guava at all. Like other reviewers, I'm also not a fan of the packaging. I usually apply this at night since it leaves a whitish cast on my lips if I slather it on (a little goes a long way). If I use just a little, it doesn't leave me with white lips. I've tried the colored lip butters and this one is the most moisturizing so far. — 5 years, 5 months agomihshelle | 182 reviews
This review is: Helpful | Not helpful | Inappropriate | 8 of 11 people said helpful
Pretty colors but the packaging is a little awkward.I own this in Quince, Plum, Jasmine, and one other. The colors are really pretty and can be applied sheer or layered on for a little more color. I like the range of colors, and the cute packaging with the color coded lids. It smells nice and faintly fruity, but not in a plasticky or artificial way. The price is fairly average. I don't like the packaging in that you have to stick your fingers in th...read moree pot and the wall of the container is kind of thick, making it awkward to try and get some product out. I'd probably prefer the new squeeze tube version. It also isn't as moisturizing as I'd expect a "lip butter" to be. Overall, it's an okay product, but I'm not sure I'd repurchase. — 6 years, 5 months agoLipglossandSpandex | 521 reviews
This review is: Helpful | Not helpful | Inappropriate | 1 of 2 people said helpful
Review: Korres Natural Products Guava Lip ButterI LOVE these! A staple in everyones bag. They have cute packaging, an okay price($10) and they feel very moisturizing. — 6 years, 5 months agoaly7 | 396 reviews
JasmineI have this in Pom & Wild Rose as well but Jasmine smells and tastes divine! These butters are perfect! They provide a nice pop of color and soothe my super chapped lips almost instantly. I love putting this on before bed because I wake up with pillowy soft lips the next morning. The jars are cute and a little high priced but totally worth every penny! — 6 years, 10 months agopynkNymphette | 197 reviews
This review is: Helpful | Not helpful | Inappropriate | 2 of 2 people said helpful
Like butta!I really like the way this glides onto my lips. The guava is di-vine!!!! It leaves my lips feeling smooth and supple. It doesn't feel heavy at all. The only thing that I don't like is that it doesn't have SPF. That would up the rating soooo much more. Just like we protect our skin, we need to protect our lips. — 7 years, 3 months agosweettpea29 | 280 reviews
This review is: Helpful | Not helpful | Inappropriate | 4 of 5 people said helpful
To Buy or Not to Buy?Since this is a very much talked about product and considered a little high end, I believe I should give this an extensive review. I received a few in a gift set over the holidays and I'm actually very glad I did not purchase these lip butters with my own money! That's not saying this is a bad product by any means, but I believe there are better ones out there at better prices. Starting with the f...read moreormula: this lip butter is very emollient and smooth when applying from pot to lips, though I don't believe the term 'butter' comes from the way it applies, but more of how it's not as stiff and waxy as a traditional lip balm in stick form. However, it FEELS like a traditional lip balm given how it just sits on my lips like a film instead of melting into them. Here's where the hydration factor gets a little iffy because of that film-like application since it didn't actually moisturize my lips but neither did it dry them out. I can best describe it as this product 'maintained' the moisture in my lips. If my lips were dry, they remained dry. If my lips were moist (such as after washing my face), they remained moist. Formula aside, this lip butter can be considered more than the traditional balm because of it's pigmentation and shine. My lips have a color of their own and I can add this on top to give me more of a "my lips but better" sheen. The downside to the lip butters having color? Guava and Jasmine definitely give the lips an unnatural white color! Lastly, it should be said that many may not find this lip butter appealing due to its packaging and fragrance (note that the names are given based on shade and the extract added in, not necessarily the smell)! The scent varies between shades, but all came through balm-like and a little herbal-y to me and because the product comes in a little pot (with very strange sides that curve inward!), application is also a little messy and unsanitary. All in all, I must recommend another tinted balm such as Burt's Bees over this one simply for the fact that this one was not very hydrating and because I could get better results (as well as equal color) from a much cheaper product! — 4 years, 6 months agotheycallmerainbow | 106 reviews
This review is: Helpful | Not helpful | Inappropriate | 0 of 1 people said helpful
Fabulous!!!I was saddened to find out that MAC had discontinued their Tinted Lip Conditioners which were my previous HG. I guess it was a blessing in disguise because these are soooo much better! Although you get a lot less products these are so much smoother and don't feel waxy at all! Just nice and creamy with a buildable pigment. Super hydrating as well. I currently own Jasmine, Pomegranate, and Wild Rose...read more and look forward to picking up the rest of the colours as well as trying out the lip butter glazes. — 4 years, 6 months agoCliniqueLover | 297 reviews
Korres Natural Products Lip ButterI recently picked up the Korres Wild Rose Lip Butter at Ulta. I keep something on my lips at all times because they have a tendancy to become chapped and dry if I don't. I don't usually like potted lip products, but I use a brush with this and it works really well for me. It has no scent, it is delicately pigmented, the color is a really nice opaque rosy reddish color, it is very nice. It work...read mores well for me, it keeps my lips moist, has a natural but better than natural lip finish, it has a nice glossy finish. I feel it helps protect my lips, and it doesn't bleed or feather. It works really nicely under my lip stick, and my lips aren't chapped or dry when I use it. It seems to ward off the extremes in elements where I live, it is extremely hot in the summer and polar cold in the winter, and if I keep this on, my lips are nice. I find it isn't sticky or greasy, it feels as nice on as it works for me. It comes in many formulations so anyone could find a variety that would please them, it is a really nice product in my opinion. — 7 years, 9 months agolesa5363 | 352 reviews
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My Reasons for Reporting This


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Washington Redskins QB Robert Griffin III will marry fiancée Rebecca Liddicoat this summer, his mother, Jackie Griffin, told MyFoxDC.
The couple was engaged in 2010 following a proposal after Baylor clinched its first bowl game in 16 years. RG3 proposed at the team's training facility.
"I didn't want to do it on the field like the big cliche. So actually did it after the game, brought her to our indoor facility," Griffin III told Jay Leno. "I tried to trick her by saying that we were going to do something that the whole team was going to do at the (facility) after we won.
"No one was there when we showed up, but she still believed me. Had a guy in there playing guitar; I sung her a song; had candles in the middle of the field with her family and my family holding them. Had to do it the right way."
Robert Griffin III underwent successful knee surgery in January that included a direct repair of his LCL and a "re-do" of his previous ACL repair. He suffered the injury in a wildcard playoff game against the Seattle Seahawks.


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A.Mutt got me thinking about all the possible applications of oil-based masking agents. Say you were to do a 3-color (red, blue, yellow) dye on a white disc. Can oil help? This is my thought:
Step 1: weed and dye the first color.
Step 2: coat the first color with a thin layer of veggie oil, and let it "dry" to gumminess like oil does.
Step 3: weed and dye the second color.
repeat 2&3 for the third color, then wash all the oil off the disc.
Hmmmm, as I was writing this I reminded myself of Elmer's glue- perhaps that would work better than oil, and it would cure a lot quicker. Didn't BennettUA say that Elmer's glue takes some of the dye out of the plastic, but not enough to cause a problem?
Would you even need to let the oil dry, or would it travel to other areas of the disc whilst dipping?
Another problem I can foresee is contaminating your dye with oil, but it shouldn't be TOO hard to get the oil out with a paper towel laid on the surface of the dye. Could be messy, though.


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Vogue Bronze Mattress - Small Double
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Durham meets Joe Biden
"I'm here because Joe Biden fights for the middle class ... and he's the perfect person to get me fired up on a Monday morning."
—Joe from Raleigh
"I brought my grandson with me today because this election is about his future."
"Joe Biden is just awesome, plain and simple. As a college student, I know that he is fighting for me."
Supporters in Durham, North Carolina gave Vice President Joe Biden a warm welcome today. At the event, a few folks shared why they look up to the Vice President, and why they'll keep working hard for him in the final 85 days of this election.
"In Joe Biden, I see the same working class background that my father came from. I admire my father for how he works for others, and I admire Joe Biden for that same reason."
—Rachel, a neighborhood team leader in Chapel Hill
"You don't have to be a billionaire for Joe Biden to care about you. He is for all Americans."
"Joe Biden is honest, and you see every day that he is working for people like us."
—Billie and Mozelle
"In Joe Biden, I see the values that I care about. That's why I work so hard every day."
—Chrissy, a neighborhood team leader
"The choice couldn't be clearer now, and Joe Biden is the one fighting for everyday Americans."
Lend the Vice President a hand while he's out on the campaign trail—get involved in your neighborhood today.


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Ohio does not have a federally approved occupational safety and health regulatory program. Consequently, federal occupational safety and health standards govern private sector workplaces in the state.
The state has adopted by reference the federal emergency action plan standards for public sector (state and local government) workplaces (Ohio Administrative Code 4167-3-01) in general industry and construction.
The U.S. Department of Labor/Occupational Safety and Health Administration (OSHA) administers and enforces federal workplace safety and health requirements in private sector workplaces. The Ohio Bureau of Workers' Compensation/Division of Safety and Hygiene Services administers safety and health rules for public sector workplaces.


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from Traversée des vieilles voitures en couleurs by PBase member Blandine Mangin
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There might be a mistake in the URL you entered. Please check the address and try again.
There is no image with id 91594849. It may have been deleted.
Email email@example.com if you have any questions.


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Carencro Man Attacks Father With Samurai Sword, Will Face Attempted Second Degree Murder Charges
CARENCRO, La. (KPEL) — A 32-year-old Carencro man has been arrested after he allegedly attacked his 63-year-old father with a samurai sword during an argument.
Capt. Kip Judice with the Lafayette Parish Sheriff's Office says deputies were called out Wednesday afternoon to the home on St. Esprit Road in Carencro after receiving reports of a domestic abuse at the home.
"Deputies arrived to find [the victim] with several chop-like injuries to the hands, arms, and head," Judice says.
Police believe the father was trying to counsel his son, but the discussion soon escalated into an argument. The son, Albert Price Prejean, left the room, came back with the samurai sword, then struck the father four times.
Judice says it appears Prejean was trying to strike his father's head.
As the father tried to defend himself, Judice says the two apparently fell, "and the son received a cut to his leg as well."
Prejean was taken to University Medical Center in Lafayette where he remains under guard until he's medically cleared to be transferred to the Lafayette Parish Correctional Center, Judice says. He will be charged with attempted second degree murder once released, Judice says.
The father was treated for non-life threatening injuries, Judice says.


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Moderators: Timko, Fritz, Solty, Booter, Blake_T, Frank Delicious
The only course confirmed for any division is Franklin-Simpson on the short pads for the Advanced players. All other courses and divisions will not be up until next week.
ziggy wrote:Didnt play the CCC last year - hadda work at http://www.deafnation.com/page.php?id=447 catering to 5,000 customers in one day.
Wont ever be able to play the CCC until either/or CCC/Deafnation moves it date from the first weekend of October (
Me and my lady will be down at Bowling Green with our thumbs sticking out for a ride so Jorr - if you got room - let me know!!
So far - only 2 deaf people have registered. (me - Kent, and John Buck)
Jwt4412 wrote:Ziggy,
We are going to be there anyways... right?
How do we register?
Users browsing this forum: No registered users and 1 guest


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Enjoy the Holiday Spirit
Folks are busy shopping for great bargains, the market closes early today, and there is probably some pumpkin pie left in the refrigerator so why shouldn't we have upbeat market action this morning? All is well, and traders are running up a few stocks to bank quick gains.
Breadth is very strong, with 3850 gainers to just 1050 decliners, and all major sectors in the green. Precious metals have come to life and are attracting speculative interest for the first time in a while, and biotech and even semiconductors are active again. Research In Motion (RIMM), Nokia (NOK) and some of the other long-term laggards are catching bids....96 more words left in this article. To read them, just click below and try Real Money FREE for 14 days.
There's no substitute for a trading floor to get great ideas, so Jim Cramer created a better one at Real Money and blogs there exclusively. We then added legendary hedge fund manager, Doug Kass, with his exclusive Daily Diary and best investing ideas. Staffed with more than 4 dozen investing pros, money managers, journalists and analysts, Real Money Pro gives you a flood of opinions, analysis and actionable trading advice found nowhere else, and allows you to interact directly with each expert.
Already a Subscriber? Please login.


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ARDEN HILLS, Minn. — Land O'Lakes has promoted Mike Macrie to the position of VP and chief information officer. Macrie replaced Barry Libenson, who after running IT for three years, left the company to be CIO at Safeway.
Macrie joined Land O'Lakes in 2010 as VP and senior director of Ag Services IT.
"Mike has shown tremendous leadership through the successful transformation of Ag Services technology, including our proprietary R7 satellite imaging platform and rebranding of Winfield and Purina across intranet and customer sites," said CFO Dan Knutson. "It's a testament to the internal bench of talent built at Land O'Lakes that gives us the opportunity to promote an internal candidate to CIO."
Macrie previously held a number of roles at Ingersoll Rand, AlliedSigna, G5 Technologies and Multi-Media Solutions. He has an MBA from Duke University and a bachelor's of science from Cornell University in applied and engineering physics.
"As Land O'Lakes focuses on accelerating growth, Mike and the IT leadership team will help drive our business transformation through technology, achieve returns from our IT investments and support our co-op's IT growth needs," Knutson said.
Land O'Lakes is a national, farmer-owned food and agricultural cooperative with annual sales of more than $14 billion. The nation's second-largest cooperative,, Land O'Lakes does business in all 50 states and more than 60 countries. It is a leading marketer of a full line of dairy-based consumer, foodservice and food ingredient products across the United States; serves its international customers with a variety of food and animal feed ingredients; and provides farmers and ranchers with an extensive line of agricultural supplies, such as feed, seed and crop protection products and services, under the operations of WinField and Purina Animal Nutrition. Land O'Lakes also provides agricultural assistance and technical training in more than 25 developing nations.


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- Home
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Museum Boijmans Van Beuningen has acquired a unique drawing by the 16th-century artist Pieter Aertsen. 'The Sacrifice of Iphigeneia' is one of the few known drawings by the master and is the first of his works on paper to be acquired for the extensive collection of drawings housed in the museum.
The Amsterdam-based artist Pieter Aertsen (1507/8-1575) gained great popularity through his combination of religious images and kitchen interiors, market scenes or lavish still lives depicting fruit and vegetables. It made him one of the most famous painters of his era. Aertsen also made a number of drawings, of which only eighteen are known to exist worldwide.
'Lange Pier'
Museum Boijmans Van Beuningen has now succeeded in acquiring one of Aertsen's drawings. While the museum possesses one of the most important collections of 16th-century Dutch art in the world, including four paintings by Aertsen, until now it did not have one of his drawings. The acquisition of 'The Sacrifice of Iphigeneia' fulfils a long-harboured desire. Stylistically, the pen and ink drawing is in keeping with Aertsen's other drawings, which are characterised by their smooth, elegant style. His elongated, mannerist figures earned Aertsen his nickname, 'Lange Pier'.
Greek tragedy
The drawing is one of the two mythological images that Aertsen is known to have made. It depicts a scene from the tragedy 'Iphigeneia in Aulis', written in 406 BC by the Greek dramatist Euripides. Iphigeneia was to be sacrificed by her father Agamemnon, leader of the Greek armies, to placate Artemis (Diana), the Goddess of the Hunt. At the last moment however, Iphigeneia's terrible fate was averted by Artemis herself, who made her invisible and carried her off unseen. The drawing depicts the moment when Agamemnon raises his sword to run his daughter through.
Technical details
Pieter Aertsen (Amsterdam, 1507/8-1575)
The Sacrifice of Iphigeneia, c. 1560
Drawing in pen in brown on paper
119 x 260 mm
The drawing was acquired from a Berlin-based art dealership during the annual Salon du Dessin art fair in Paris. The acquisition was financed with funds from a bequest by Mrs N.C. van Riemsdijk-Borsje (2006), intended for the museum's collection of Old Masters.
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Feisty (Foster), Hulk (David Harrison), and now Franchise (Roy Hibbert) are the only ones that come to mind. Although some people have been throwing around the Smooth for Dunleavy recently, I just don't see it. I mean, there are abbreviations that get around, but they are pretty self-explanatory: Murphleavy (usually in reference to their contracts and/or the GS trade), Dun-Dun, JT, Hibby, Quis (and the threesy variety), JO, Jax (used for both Mark and Stephen Jackson), SJax, Cro, AJ, Big Al etc. Any references to "Fingers" are not basketball related, and we'll leave it at that. The Black Hole can refer to any number of past Pacer players, but it is most often applied to Al Harrington or JO due to the fact that passes thrown to them (in the post) are rarely returned (or seen again). Jamaal Tinsley, aka the Tinman, has also been known by several disparaging nicknames; "Mel Mel the Abuser" from his street ball days and "Dustpan" thanks to his janitorial efforts at the brawl are just two that come to mind.
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