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Brand Name: Dafen Village Frame: Yes Technics: Spray Painting Original: Yes Frame mode: Unframed Subjects: Flower Medium: Waterproof Ink Shape: Irregular
Type: Canvas Printings Style: Modern Form: Combined
Material: Canvas Calligraphy and painting type: Canvas Painting Support Base: Canvas
Model Number: Home decoration quality: AAA+++ Decoration: home, house, office, hotel, restaurant. no framed: rolled in a tube. with framed: ready to hang at wall.
is_customized: Yes Calligraphy and painting Size: 20x35cmx2,20x45cmx2,20x55cmx1
Type: Printed
Package is more favorable WELCOME to my store on Aexpress,Where providing high quaty 100% GUARANTEED Print painted on canvas paintings . outstanding prices along with first CUSTOMERS CARE is our main goal. Thanks for you coming. 24 hour's onne (Look forward to your advice) Material Canvas Print with Linen/Cotton High quaty Material. Quaty rating AAA+ High quaty. Stretched and framed Unstretched (rolled in a tube) buy: no framed.
Stretched (framed on the back,ready to hang out of the box) buy: with framed. Customer Service We can custom any size for you, and we can do custom canvas prints too, you just need to send us high resolution picture. Size size1:20x35cmx2,20x45cmx2,20x55cmx1 (8x14inx2,8x18inx2,8x21inx1)
total width 100cm
size2:30x50cmx2,30x65cmx2,30x80cmx1 (12x20x2,12x25inx2,12x32inx1)
total width 150cm
total width 200cm Shipping The Shipping way will choose as below piority.
1. China Post Air Mail
2. EMS Devery time 1. China Post Air Mail: Normally 15 - 50 days, but to Brizal maybe need 2 to 3 months. If you can not wait so long time, please do not purchase it or choose other fast shipping way. Thanks!
2. EMS: 7 to 10 days
1 Genuine 100% "Top Quaty" Canvas print paintin MADE IN CHINA. 2 It as a wonderful gift for your friends and It is the perfect frameless will dramatically energize your home, office, or garden. We only choose the best 100% canvas material . OUR Production process.
Dear My Friend PLEASE VIEW THE NOTICE BEFORE YOU BID AND PAY. 1. The product is made in CHINA . 2. Negative feedback does not solve anything. If you have a problem about our transactions, please contact us first. We are always wilng to work things out. 3. If you do not get the item after you payed 28 days,please contact us; we would do our best to solve it ! 4. We will ship to the address you left on Aexpress when you ordered, please confirm your shipping address on Aexpress is correct when you pay. If you need to change your shipping address, please must leave us a message with payment. I was a newly graduated college students,this is our new shop, We need dear friend support. We will put their best foot forward to show everyone .please beve us,We will give you the best goods and best service. Feedback and Contact us 1 If you are not satisfied with this transaction for any reason, please contact us before leaving neutral or negative feedback. Please give us a chance to do our best to solve the problem. 2 All our products have been checked and packaged in good condition before shipment. If the purchased item you have received is defective, please contact us ASAP, we would settle it. Welcome to OUR Shop,choose you fe,happy every day. 1) WORLDWIDE SHIPPING. (Except some countries and APO/FPO)
2) The images shown are not the actual item and are for your reference only.
3) SERVICE TRANSIT TIME is provided by the carrier and excludes weekends and hodays. Transit times may vary, particularly during the hoday season.
4) If you have not received your shipment within 30 days from payment, please contact us. We will track the shipment and get back to you as soon as possible with a reply. 5) Drop shipping. We provide drop shipping that can directly send products to address with detailed info. 6) We are not responsible for any tax and duties at destination. 1) We provide 7 days unconditional return even though this article is good, not defective. You have 7 days to contact us and 30 days to return it from the date it was received. If this product stays in your possession for more than 7 days, it is considered being used and WE WILL NOT provide this service. All shipping cost which includes we shipping out and you sending back is borne by buyer. We will issue refund full bid amount excluding the shipping cost upon receipt of the product.
2) If the product(s) is (are) not as advertised or defective, please return us in 7 days . We will refund YOUR FULL WINNING BID AMOUNT, upon receipt of the item in its original condition and packaging with all components and accessories included, We will bear all the shipping cost. AFTER BOTH Buyer and Seller cancel the transaction from aexpress. OR, you may choose to have a replacement, or ask for disccount without sending back product. 3) All returned items MUST BE in the original packaging and you MUST PROVIDE us the tracking number, specific reason for the return. 4) 60 days unconditional refund. If you are not wilng to wait after the product(s) is (are) shipped out for 60 days, we will refund you full winning bid amount. 1) Please kindly leave us positive feedback if you are satisfied with our product and service. 2) Please contact us before leaving any negative or neutral feedback. We will right any wrongs and give your 100% good answers.Thank you for your understanding. Feedback: 1. If anything make you aren't satisfied or angry,please cantact usdirectly before leaving feedback,We will try our best to slove the problem until you satisfy. 2. If you satisty with the item,please leave a positive feedback (5 star) for us, It is very important for us.
Product Description
Packaging Details Unit
Type: set
Weight: 0.500kg (1.10lb.)
Package Size: 30cm x 6cm x 6cm (11.81in x 2.36in x 2.36in)
If you would like to pay by PayPal, you can pay to our PayPal account: email@example.com and email us. Please email us the name of the product, the quantity and other product attributes. The email address is firstname.lastname@example.com. No matter how many goods you buy in one order, the freight you need to pay is only 15 dollars
1. WORLDWIDE SHIPPING. (Except some countries and APO/FPO)
100% Money Back Guarantee on each item. Please contact us within 24 hours upon your receipt of the items. A full refund including shipping will be rendered in the event that the item is not as described. The refund will be rendered once the item has been sent back in original condition.
Customer Reviews:
Displaying 1 to 6 (of 7 reviews)
by Christine Wilson
Date Added: 06/29/2017
Delighted with the serviceMy order arrived quickly and was beatifully packaged. Thank you!
Rating: [5 of 5 Stars]
by Lesley Gent
Date Added: 06/29/2017
Wonderful serviceI have some Chiruca boots from Easy Wellies, I needed to change my order form my original choice, but the staff were very helpful, and I am very please with the boot. I am a size 6 but ordered a size 7 as I need to use an instep support and always wear thick socks, this is fine and the boots are very comfy and warm. Thank you so much for the excellent service, prompt delivery and quick refund on the previous purchase which was not suitable. I will use you again and recommend you to friends.
Rating: [5 of 5 Stars]
by ANITA WOOD
Date Added: 06/29/2017
FIRST DIVISIONThe web site was easy to use, with lots of helpful information and guidance links for sizing etc - I ordered on Wednesday and the goods were delivered on Friday, one of the best interenet shopping experiences EVER. First Class. I cannot rate this company highly enough. Will definately use again.
Rating: [5 of 5 Stars]
by Pallavi
Date Added: 06/29/2017
Very happy with my new shoes Fast and reliable
Rating: [5 of 5 Stars]
by Thomas Stenhouse Rosyth, GB
Date Added: 06/29/2017
02 September 2011
Go no where else I ordered 2 hooded tops for my company. No one beleaved me that the cost was for embroidered logos and text. Cant wait to show them tomorrow.
Rating: [5 of 5 Stars]
by Barkaway Woking
Date Added: 06/29/2017
07 November 2011
Brilliant Excellent company with prompt delivery and very happy with my product Comment (0) Find useful Reply as company Report Paul Knox-johnston Whiteley, GB
Rating: [5 of 5 Stars]
Displaying 1 to 6 (of 7 reviews)


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Have you noticed that your marketing efforts seem to be consistently losing their effectiveness? Have you experienced a steadily declining ROI (return on investment) with your marketing? Are you wondering why you're spending more for marketing and advertising… but seeing declining numbers of prospects raising their hand and asking for more information about what you sell?
What you need to know…
What business owner hasn't experienced the frustration of spending their hard earned marketing dollars and failing to generate any interest or response? What's responsible for these constantly declining results?
Don't be offended by what I'm about to say… but it's YOU! You're a marketer, and today, people hate marketers. They will do just about anything to avoid any and all marketing and advertising messages. Don't believe me? Check out yourself. Do you have caller ID on your phone? Do you answer it if you don't recognize the incoming number? Does your computer have a version of spam blocking software? Are you on the national do-not-call list?
Why you need to know this…
We have to face the facts. The old ways of marketing don't work anymore. The key to all future marketing is establishing trust, respect and rapport with your prospects. The internet is the social networking platform that is changing the face of all marketing today.
Every single day your prospects and clients are meeting on forums, blogs, and sites like LinkedIn, Twitter, Instagram, Snapchat and Facebook. They're producing podcasts and YouTube videos. They're comparing notes bragging and recommending the products and businesses they love, and they're blogging to death about the ones they hate.
And everything these prospects say to their peers has far greater impact and influence than anything you will ever say, no matter how great a message you create. The latest research shows that our peers are currently the most trusted people on the planet, and you MUST gain their trust to get them to recommend your product or service.
The cost to you if you fail to act…
- Do you know how to innovate your product or service to take full advantage of the internet and social media?
- Do you know how to stop marketing to prospects and instead, start talking with them?
- Do you know the 6 places where your prospects will meet to talk about your business?
- Do you know how to position yourself as the "industry expert"… and become the "rock star" of your local community?
If any of the above answers are no, you're losing sales and revenue every day. You're going to appear identical to your competitors, and be forced to forever compete on price. If you fail to innovate your business… and you fail to provide extraordinary value to your clients… your prospects will use the internet to blog your business to death.
You MUST learn how to develop these critical skills immediately!
I can help. My coaching provides business owners with the right information in the right order to successfully grow their business online even without a massive social media following.
In fact, one of the number one questions I get from business owners, is how do I grow my presence on social media because they think that is how you get clients. But I want to give you some good news, you do not need a large following on social media to succeed and get clients within a very short period of time if you understand how to build an online business.
If you find you could use some help in this area contact me for one on one coaching today!

subset: commoncrawl


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Feb 18
Greetings Fellow Fish Enthusiasts,
It's a great day over at Elegant Reef! Blue Hippo Tangs are back in stock with three sizes to choose from ranging from 1″ to 5″. Mystery Wrasses have also re-appeared and we are excited to have one available this week! If you missed our last post we still have a few amazing animals from previous shipments like an eating White Tail Bristletooth Tang, Frostbite Clown, Platinum Clown, & Blue Spotted Jawfish!
We are also expecting a shipment of premium Acans later in the week, you won't want to miss those!
And now, without further ado, here's what's newly available:
Eibli Angel (Indo)
Lemon Peel Angel (Haw)
Whitetail Pygmy Angel
Bicolor Angel (Fiji)
Blue Tang 1″-1.4″
Blue Tang 2.5″-2.9″
Blue Tang (indo) 4″-5″
Mysteri Wrasse
Three Spot Domino Damsel (In
Honey Damsel
Phillipine Yellow Tang
Africa Cleaner Wrasse
Shark Finned Wrasse
TriColor Fairy Wrasse Male Md
Lubbock Fairy Wrasse
Copperband Butterfly Md (Indo)
Pakistan Butterfly (Indo) Md
Bicolor Blenny (Indo)
Clown Yellow Goby
Firefish Goby
Purple Firefish Goby
Mandarin Green Goby Md
Mandarin Green Goby Lg
Mandarin Spotted Goby Sm
Lawnmower Blenny Sm/md
Diamond Goby Md
Tail Spot Blenny
Watchman Pink Spotted
Pantherfish Md
Saddle Puffer
White Spot Puffer (Haw.)
Powder Brown Tang Md
Sailfin Tang (Indo) Md
Six Line Wrasse (Indo)
Yellow Coris (Srilanka)
Flasher Wrasse-Male
Cardinal Blue Eyed
Hawkfish Longnose Md
Pseudo Chromis Purple
Squamipinnis Male
Ritteri Anemone (Indo) Md
Porcelain Crab
Strawberry Crab
Halloween Hermit Crab Lg
Electric Blue Hermit
Cleaner Shrimp Md
Peppermint Shrimp Md (Car.)
Sand Shifting Starfish
Featherduster Md
Turbo Snail (Mex.)
Cerith Snail
Astria Snail (Florida)
Nassarius Snail Xlg
We bring new livestock in every week and there are already so many beautiful specimens to choose from. Stop by and check it out!
I'll see you at The Studio!


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Serious gamification for serious threats
Thank you for attending our webinar on how behavioural science and gamification can create truly transformative learning. Or if you missed it, you're in luck.
Sign up here to receive:
- A summary of key takeaways and insights — behavioural science to apply to your own learning
- A link to the webinar recording
- A carefully curated reading and watching list from presenter James Tyas
If you already registered for the webinar through the Saffron website, there's no need to enter your details again. We'll send out the document automatically.


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Mills was formed in 1952 by the Nacht family, as a scaffold and shoring company which provided services to the civil construction sector. Mr. Andres Cristian Nacht was a member of our management team from 1969 to 1998, being president director from 1978 till 1998. In 1998, Mr. Andres Cristian Nacht became Chairman of the Board of Directors of Mills, position occupied until April 2018.
Decade of 70/80
In the 70's and 80's, we had substantial growth due to the significant civil construction and industrial sectors expansion in Brazil. Among our activities from this period we can highlight the construction of the Rio-Niteroi Bridge (1971), the Itaipu Hydroelectric Plant (1979) and the first Brazilian oil drilling platform (1983).
During this period we made important partnerships with international companies that cooperated with Mills' development. From 1974 to 1986, GKN plc, a large British conglomerate, was our shareholder, strengthening the beginning of good governance and credibility. In 1980, we signed a partnership with the Canadian company Aluma Systems Inc., the Aluma Systems Concrete Forms and Formwork Ltda., which had as main objective the introduction of aluminum forms in the civil construction sector in Brazil which lasted until 2001.
Decade of 90
In the 90's, while seeking to expand our portfolio of services, we made new strategic partnerships. In 1996, we entered into a licensing contract with the German company NOE-Schaltechnik Georg Meyer-Keller GmbH, to produce and supply modular steel and aluminum panels formwork to the Brazilian civil construction market. In 1997, we entered into a joint venture partnership with the American company JLG Industries, Inc., to begin activities in the equipment rental sector in Brazil.
In 2001, the Argentine company Sullair Argentina S.A., replaced JLG Industries, Inc. as our partner in the in the industrial equipment rental venture, and subsequently acquired our stake in 2003.
In 2007, the private equity funds, Peninsula FIP, managed by IP, and the Natipriv Global L.L.C., managed by the Axxon Group, became our shareholders, acquiring, each one, 10% of Mills for R$ 20 million. The resources from these investments were used, mainly, to acquire equipment.
In 2008, we returned to our activities in the rental segment in an organic way, with the establishment of our Rental Division, and suspended the operations of our Events Division, which was responsible for providing temporary structures, such as outdoor stages and grandstands for the sports and entertainment segment, as an objective to focus on the segments where we have competitive advantages. Also in 2008, we acquired Jahu Indústria e Comércio Ltda., which became our Jahu Division, focused on providing engineering services to the residential and commercial civil construction industry, complementing our activities in the Heavy Construction segment.
Mills' IPO was on April 2010, with a transaction totaling R$ 685 million, of which R$ 411 million related to the primary offering that, consequently, were used to enable its growth plan. Shortly after the offer, Mills' free float was of 48%.
In October 2010, after the expiration from the lock-up period, the private equity funds sold the joint participation of 6.2% of Mills' capital, increasing its free float to 57.2%.
In January 2010, the Company entered into a purchase and sales agreement to acquire 25% of the voting and total capital stock of Rohr S/A Estrutura Tubulares (Rohr), a privately held company specialized in access engineering and solutions for civil construction, for R$ 90 million. This strategic acquisition enabled the Company to broaden its exposure to the sectors it serves, especially in the areas of infrastructure and the oil and natural gas industry.
In May 2011, the Company entered into a purchase and sales agreement to acquire 100% of the voting and total capital stock of GP Sul, one of the largest players in the suspended scaffold rental market to residential and commercial construction in the state of Rio Grande do Sul, for R$ 5.5 million. This strategic acquisition enabled the Company to become the leader in the suspended scaffold rental market in the state of Rio Grande do Sul and broaden its exposure to the residential and commercial construction market in the South region, in line with the geographic expansion plan of the Real Estate business unit.
On July 10, 2013, the Company entered into a sale agreement of its Industrial Services business unit to FIP Leblon Equities Partners V, a fund managed by Leblon Equities Gestão de Recursos Ltda., through the sale of its stake in the company Albuquerque Participações Ltda. The sale price set on May 31, 2013, trading date base, was R$ 102.0 million. The transaction was completed on November 30, 2013, and the price was updated.
This sale was made in line with the Company's strategy to focus on businesses where their skills are able to generate greater value for its shareholders and customers. Therefore, the Company ceased to operate in the Industrial Services sector where they were offered access services, industrial painting, surface treatment and thermal insulation, both during construction and in the maintenance phase of large industrial plants.


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You Have No Idea How Much I Love You + Introduction
Documentary (2016)
76mins Pol
Starring: Bogdan De Barbaro, Hanna Maciag, Ewa Szymczyk
Director: Pawel Lozinski
Writer(s): Pawel Lozinski
Listings: London | Rest of UK and Ireland
This Polish documentary drama smudges reality and fiction by inviting two actors, playing the roles of mother and daughter, to take part in sessions with a real-life therapist over the course of several weeks. These interactions between matriarch Ewa, her 23-year-old daughter Hanna and a therapist are captured in long, unbroken takes, teasing out the core issues and unspoken fears that have supposedly driven a wedge between the two women.
Seen that movie? Leave a comment / review here >>
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Decadanse K
{Danse Diabolique X Pablo X Falko}
Age: May 12. 2013
"Cady" is a 16.2+ hand brown mare, who was started under saddle and supposed to have a show career when the opportunity to breed to the amazing imported stallion ROYAL BLEND came along. We did not want to ship a mare and foal to Alberta to breed so the decision was made to send "Cady" this cross should be brilliant and we are anxiously awaiting her first foal in May of 2018. She will be bred again in 2018 to GRAFF.Learn More


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Your request has been received by DRG. A represantative will contact you shortly to provide more details on the research and data contained in this report and ensure that it will meet your current research needs.
Cybercitizen Health® US is a study and strategic advisory service focused on helping clients understand digital behavior and needs across the sarcoma patient experience, meet them with the right content and support in the right places, and plan for patient-centric solutions to drive outcomes.
Changing healthcare landscape: To understand how consumers perceive potential healthcare system changes in the U.S. and what's the expected impact on their health management and affordability
Healthcare costs and pricing transparency: How are costs impacting patient decisions? What are health behavior changes due to increasing health costs? What technologies are used to research costs?
Health information consumption: How do consumers read health related news? Do they trust/have confidence in information shared via social media? How to create sharable content?
Patient centricity and personalization: What type of customer service is expected in care settings or healthcare industry?
Emerging technologies: How will technologies such as AI, machine learning impact information consumption/seeking? (AI, voice search, chat bots)
Point of care everywhere (continuous care): To understand the ecosystem of continuous patient care outside brick-and-mortar doctors' offices and hospitals (telehealth, health tracking, mobile use pre and during doctor visits)
Digital patient journey: How do consumers leverage offline and online resources throughout the patient journey? What's their involvement in decision making?
Already a Client? Log in to access this report.


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New Homes in Dublin, OH
Exceptional value in Dublin! Luxury, low-maintenance ranch homes adjacent to the prestigious Golf Club of Dublin–from the $330s!
Exceptional value in Dublin! Luxury, low-maintenance ranch homes adjacent to the prestigious Golf Club of Dublin–from the $330s!
This Is It—Only 1 Home Remains! Included Finished Basement! Take entertaining to a whole new level!Find out more
If you have any questions about the community, our home models, locations and more, just click the Contact button. Click on it any time throughout our community site and I'll be happy to help!
Last Chance, only 1 remains, please call 440-220-5599 to schedule your personalized appointment!
A life of leisure can be yours at The Glens at Ballantrae. Nowhere else in Dublin offers such a well-balanced combination of gorgeous homes and lifestyle-focused amenities. You can even own a home backing onto the links at The Golf Club of Dublin!
Each of the ranch style homes we offer at The Glens at Ballantrae has everything you need on the 1st floor. You'll enjoy a spacious living area and up to 3 bedrooms on the same level, plus you can personalize with a 2nd floor guest suite. Enjoy your dream kitchen with granite countertops, elegant cabinets and stainless steel appliances. You'll even have a full basement with the option to finish.
The comforts, however, extend far beyond your home. In addition to having a golf course right next to the community, you'll also have walking trails and the 32-acre Ballantrae Community Park.
The lifestyle you want is at The Glens at Ballantrae. Schedule a visit today for a personal tour of this one-of-a-kind community!
Chosen by Business Insider as one of the top 20 suburbs in the nation, Dublin has the lifestyle you've been hoping to find. Not only does The Glens at Ballantrae sit right next to The Golf Club of Dublin, it puts you moments from a huge variety of shopping, dining and local attractions. Plus, our community is less than 5 minutes from Route 33, making it easy to commute into Columbus.
Just around the corner from The Glens at Ballantrae is a Market District by Giant Eagle supermarket as well as a Walgreens pharmacy. Nearly as close is The Mall at Tuttle Crossing with its great selection of department and specialty stores. All around the mall, you'll find some of the area's best dining from P.F. Chang's to BJ's Restaurant and Brewhouse.
You'll have just as many places to go when you're looking to unwind. Both the Columbus Zoo and Aquarium, and Zoombezi Bay are nearby, and the Dublin Rec Center is less than 2 miles away. The area is full of golf courses and parks, including Glacier Ridge Metro Park. Dublin Methodist Hospital is also just around the corner. You don't want to miss your chance to downsize in Dublin. Own at The Glens at Ballantrae now!
5655 Marmion Drive
Dublin, OH 43016
Franklin County
Our BuiltSmart approach offers better performance, energy efficiency, comfort and savings. Select one of our models to find out how
I'm happy to answer any questions you may have about living in our community.
Prefer your bedroom on the ground floor? Our First Floor Owner homes offer features to suit every lifestyle.
Live a relaxing lifestyle adjacent to Golf Club of Dublin!
I can tell you more about all the wonderful features and benefits of our available models.
Ready to start your home search? Our free Homebuying Guide can help point you in the right direction.


text: Watch The Challenge Season 25 Episode 9 Online. Best and Free Online streaming for The Challenge TV Show. We picked the best sites to stream s25e09. Simply pick a site below and click "Watch Now!" button next to it. Some of the links may be broken, please upvote the working and good links so other users see those links for The Challenge Season 25 Episode 9 s25e09 at the top of the list.


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On July 3, 2003 our first child was born - a beautiful baby girl who we named Emma. She weighed 9lbs 2 oz was 21 inches long and was just the most beautiful little angel we had ever seen. From the beginning she was a very active, alert and a strong baby. She walked by 11 months of age and began running shortly thereafter.
Two years later our second daughter, Abby, was born and 2 years after that our son, Will, was born.
Emma was growing by leaps and bounds and was generally among the tallest in her age group. She loved her pre-school at Thunderbird and by the time she was 5 she couldn't wait to ride the bus to school.
In November 2009 we noticed our Emma walking with somewhat of a gait and she mentioned that her legs felt "tight." We discussed this with our pediatrician but they felt that the discomfort in Emma's legs was most likely due to growing pains. Since Emma had a growth spurt about that time we kept an eye on her for the next month, along with getting her new shoes, trying heat packs and using Tylenol when needed to curb her discomfort.
By mid December 2009, Emma's gait became worse, her discomfort had grown and now her shoulders and back seemed to be curving so we went back to our pediatrician. The diagnosis now was possible scoliosis. It was recommended that we see a pediatric orthopedic specialist, by the name of Dr. Albert Knuth out of Barrington IL. On January 6th we had an appointment with Dr Knuth and after taking an x-ray in his office he shocked us with the news that Emma had a rare condition called high grade (level 4-5) spondylolisthesis. He then mentioned that surgery in the form of some type of decompression/reduction and spinal fusion was the only option to correct Emma's spine.
Dr. Knuth indicated spinal surgeries were not his specialty, but recommended a colleague of his Dr. Steven Mardjetko who specialized in pediatric spinal surgeries. Dr. Knuth spoke with Dr. Mardjetko while we were in the office and was able to get us an appointment with him that Saturday. We will forever be grateful for the urgency which Dr. Knuth exhibited in this situation so we could get the medical help needed for our daughter.
We could not believe the severity of Emma's condition or how quickly this had happened. We needed to act quickly to prevent any serious or permanent nerve damage. Considering her condition and age it was difficult to find a surgeon who had any history of doing this type of surgery on a five year old. Before our appointment with Dr. Mardjetko we got on the web to become more informed about my daughter's condition and found that the information was scarce since this was a condition usually associated with early teens and few doctors had any experience with Emma's age group.
Naturally, our first thought was to go to Children's Memorial Hospital in Chicago since it was considered a premier children's hospital. We had a disc of Emma's x-ray and emailed it to the head Pediatric Orthopedic Surgery at Children's Memorial Hospital in Chicago IL. A couple days after seeing Dr Knuth we took Emma to Children's Memorial. We spent the entire day there and when they saw the severity of Emma's condition they asked that we stay and discuss the surgical option with the head of Pediatric Orthopedic Surgery. Naturally we stayed and Emma was a real trooper. His approach was to decompress and reduce through one surgery, pulling Emma's spine all the way back in to place and then inserting rods and screws from L4 through S1. He also indicated that the surgery should be done in the next two to three weeks due to the severity of Emma's condition. Our concern was that he had never done this type of surgery on a child of Emma's age. If it was not, she could possibly suffer more damage in the form of nerve and bladder function.
A couple days later, on Saturday we had our appointment with Dr. Steven Mardjetko (pediatric-orthopedic surgery) out of Illinois Bone and Joint Institute in Morton Grove IL.
Dr. Mardjetko was the first Pediatric Orthopedic Spinal Surgeon that we had come across that had experience operating on a 4 year old and an 8 year old child (who was a similar size to our daughter) with this same condition. He had a different approach to her surgery. He was very open and honest indicating that he had a plan to do a decompression and reduction with a spinal fusion from L4 to S1 as a first surgery, and then after approximately six months do a second surgery to shorten the rods releasing L4 and removing the screws from L4 as well to give Emma more mobility later in life. Although we were not very thrilled to hear about two surgeries, the concept made more sense to us in the long run for Emma. Dr. Mardjetko also indicated like the others that due to the severity of Emma's case, we should make a decision in the near future (3-4 weeks) to avoid any additional problems.
Even with the short time frame for a decision we continued talking (and emailing Emma's x-ray, MRI & CAT scans) to many different specialists, orthopedics, neurologists, friends and family who had been through different kinds of back issues and surgeries. We were also checking for different world known specialists in the field of pediatric orthopedics who had specialized in the spine and who had the experience of operating on a 5 year old child with high grade spondylolisthesis. It was quite disheartening to find there weren't a lot of Pediatric Orthopedic Surgeons who had operated on a child of this age with this severe of a condition. It is a difficult process when the condition is considered rare but we were fortunate to get information from reputable doctors and our close friends as to who might be a good candidate to operate on our daughter.
One name that came up quite a few times from other doctors in the field was a Dr. Larry Lenke, out of St. Louis, MO. We emailed Emma's x-ray, MRI's and cat-scans to his office to get his opinion on Emma's condition. We wanted to know if we should be making a trip out to see Dr. Lenke or if we were in the right hands with any of the pediatric orthopedic spinal surgeons in our area.
It was a very stressful time for all of us, but mostly for Emma who was not feeling well and dealing with long drives to different specialists offices while lying in the back of the car with one of us because the pain was becoming so intense. Dr. Lenke had gotten back to us and indicated that we would be in great hands with Dr. Mardjetko. Dr. Mardjetko was our first pick, but having the blessing of Dr. Lenke to go with Dr. Mardjetko just solidified that we were making the right choice.
Another thing that a neurologist said to us was that we had to be comfortable with our pick of the right surgeon for Emma and go forward. In the end we decided that Dr. Mardjeko out of Lutheran General Children's Hospital was the best surgeon for Emma.
Emma had to endure a couple weeks of pain and discomfort and we needed to prepare for the surgery which would be occurring on Jan 21st 2009. We tried to make it as simple as possible, mostly for Emma. Between making arrangements for someone to care for our two other children, mentally preparing for what was ahead of us and our concern as to her well-being before the surgery, the two weeks seemed to happen quicker than we imagined. Throughout all of this, Emma was amazing. We discussed the situation with Emma as to what would be happening when we took her to the hospital and tried to bring it down to a five year old level. She had suffered quite a bit, but rarely complained. At this point she was crawling up the stairs in our house and her back seemed to be curved even more. But, on the morning of her surgery, she was actually excited to go to the hospital because Dr. Mardjetko was going to fix her back so that she could sit, and walk and play again without hurting. She was so excited that we were a little concerned considering what she was going to have to go through for the next 6 months to a year. It seemed as though the world stood still during the heart wrenching six and a half hour wait for her surgery to be completed.
My husband and I had already planned to stay at the hospital during the time Emma would be recovering. Our first look at Emma after the surgery made my heart sink. Her face was so swollen that she could not open her eyes because she had to be on her stomach for the 6 ½ hour surgery. She was crying when we first walked into the pediatric ICU because she was scared, in pain and couldn't see because her eyes were swollen shut. But once we got there and held her hand she seemed to be able to calm down a bit.
By the next day the swelling was going down but new challenges had just begun for Emma and for us. Dr. Mardjetko had indicated that Emma would need to be on bed rest for at least a couple months to let her nerves settle down from the surgery. The good news was that she could wiggle her toes which hopefully meant that there was no nerve damage but the nerves needed to heal from the stress of the surgery. This would unfortunately cause her a lot of pain and she was also susceptible to bouts of uncontrollable crying. Each day was better and each day was a challenge especially trying to keep your spirits up for yourself, your family and your child.
Emma spent 2 weeks in the hospital recovering from surgery. Day 2 after surgery she was measured and fitted for a brace with leg cuffs that needed to be worn when ever she was not lying in bed. The pediatric unit at Lutheran General Hospital has some phenomenal individuals that help take care of the kids, from the nurses and doctors to the volunteers.
Although there were some very difficult times for Emma in the hospital, with catheters, IV's, Physical therapy, a urinary tract infection, medications, a brace, leg cuffs and bouts of crying, there were also some wonderful moments. Like, the pet therapy program, where Emma was able to enjoy petting and even cuddling with one of the little dogs. She also was very enamored with the music therapy program where she was able to play a harp at one point and the musicians would come to play songs for her while she was doing physical therapy which was both mentally and physically exhausting for her as well. She loved doing arts and crafts and would send some of her projects home for her sister and brother.
On February 3rd after two weeks at Lutheran General we finally came home. Emma was restricted as to moving (being in a wheelchair for only one hour per day at first) and we had the hospital bed, potty chair and wheelchair ready for her. For the next two months she was not allowed to walk and would need to be carried, while wearing her brace whenever she was out of bed. We decided to put her in the media room which was on the second floor of our house where she would have more room for the hospital bed and potty chair and could also have some privacy when she wanted to rest. We kept the wheelchair downstairs so she could join the family for meals and get-togethers.
One of the best things to happen during this time was the tutoring that was set up through the school district. Miss Cindy would come for 2 hours every day, just as though Emma was still going to school (kindergarten without the other kids). Emma really enjoyed her school time and Miss Cindy was a wonderful teacher. I think it would have been very difficult to keep Emma occupied and still excited about learning without this.
After two months, therapy was begun to help Emma re-learn walking. We had a Physical therapist come to our home twice a week and it was very difficult for Emma. Initially I believe she was afraid, for so many reasons but being the trooper that she is, she soon began to try and walk again. First she had to learn to sit up on the edge of the bed, then it progressed to trying to stand, and then finally to taking her first steps once again. It was a miracle to say the least to see her walk once again after all that she had gone through.
Our next big hurtle was her second surgery scheduled on June 4th of 2009. We were a little concerned that she would remember all the things that happened during her first surgery and it might be difficult to get her back to the hospital. But, again she came through in great style. She walked into the hospital like a trooper and her biggest concern was that she wanted to be home to celebrate her younger sister Abby's 4th birthday that was on June 13th. Even though she had to wait until noon after not eating the night before because of a mix-up with the rods/pins, she did not complain. Instead we got a room with a TV and watched some shows and played checkers to pass the time. I actually got to escort Emma to the operating room at her request and held the anesthesia mask (strawberry flavored, of course) over her little face until she fell asleep.
The experience of post-surgery the second time around was so different than the first. Emma was up and walking after a day and we only spent four days in the hospital this time. We didn't need the wheelchair, but she did use the walker for a period of time to gain her strength and stability back. She only had to wear her post surgical brace for a couple weeks afterwards which was very exciting to Emma.
Emma was doing well after her second surgery and had restrictions from athletics and even swimming until her scar was completely healed. By the end of July 2009 we had Emma in swimming classes and she loved it. Finally, she could do something athletic and not worry about hurting her back. Toward the end of the summer 2009 we noticed that Emma's legs were getting tight and we went back to see Dr. Mardjetko in August 2009. He noticed that Emma now had scoliosis and with a 26 degree curve and was concerned. So we were now on another course to correct the curve of Emma's spine.
We got in to see David at Sheck and Sirus in Schaumburg, IL and he casted Emma to get a custom fit for a scoliosis brace to help correct the now curvature of her spine. This was very traumatic for Emma, not understanding why this was happening. She thought the two surgeries would correct her back and she would be fine and now this—it was a lot for a 6 year old to handle at that point. We got through the appointment and she picked out a neon green brace that she decorated and proudly wore UNDER her clothes this time. Emma wore her brace for 18 hours per day for about 4 months and at our visit with Dr. Mardjetko we found that her spine was once again straight—it was amazing. So she didn't have to wear the brace any longer. Emma was thrilled to say the least.
Since then Emma is going strong. She was restricted from gym and recess for the beginning of 2009 for first grade, but after her cat scan in February 2010 Dr. Mardjetko allowed her to go back to gym and recess and to participate in most activities with the exception of anything relating to gymnastics.
The cat scan from February 2010 did reveal that there is a small portion of Emma's spinal fusion that is not completely fused to date, so we are currently using a spinal stimulator to try to encourage the growth of the bone in that area. We will find out in May 2010 if the bone is growing together.
Emma continues to go for physical therapy at Pediatric Place, she is swimming and thoroughly enjoying everything that life has to offer. She is at the top of her class academically, and is just simply an inspiration to those around her. She is a happy child who has many different interests, who enjoys helping others, has a contagious sense of humor and who is just an all around wonderful person. She is extremely modest about her condition and her corrective surgery and instead would rather chat with you about a day in the life of a 6 year old.
A few words from experience to anyone going through this kind of situation with a child:
1. Be thorough and do research---get to know your child's condition and what it will take to correct it. Get many professional opinions.
2. Be organized---for yourself and your child. Keep a log of questions going throughout the process and use that written log when speaking to professionals. Ask others in the family if they can think of any other questions you may not have.
3. Second set of ears---at the appointments bring another person and find childcare for other children so that you can get the most out of your visits with doctors or other professionals.
4. When choosing a doctor/surgeon---make your choice based on the facts and the experience of the professional as it relates to your child and their condition. Don't be influenced by emotions.
5. Ask for help—you will definitely need it. We did, many different times, from many different people and it truly made the bad times not so bad, not only for Emma but for our family as well.
6. Take one day at a time, and when it becomes too much take one moment at a time.
7. Be as honest as you can be with your child about their condition and what it will take to correct it. Be honest about their limitations, but creative with other things that your child can do.
Thank you to everyone who helped us through this difficult process. We couldn't have done it without you and we are eternally grateful.
Preoperative X-Rays
Postoperative X-Rays