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January 28th-February 8th 2008 Trip Report
Trip Report; Uganda Charitable Spine Surgery Mission
Prepared by Bharath Surapaneni & Isador Lieberman January 28th-February 8th 2008
Team; Isador Lieberman MD, Mark Kayanja MD, Selvon St.Clair MD, Adam Rodatt RN, Bharath Surapaneni BA Locations; Mulago Hospital, Mengo Hospital, Katalemwa Cheshire Children's Home Society Sponsors; Health Volunteers Overseas (Orthopedics Overseas), Scoliosis Research Society (Global Outreach Program) Corporate Sponsors; Medwish Inc, Synthes Spine Inc, Kyphon Inc, Cleveland Clinic Local Physicians Dr. Deo Bitariho (orthopedics-Mbarra), Dr. Malan Nyati (orthopedicsMulago), Dr. Geoffrey Madewo (orthopedics-Mulago), Dr. Fulvio Franchesci (orthopedics Katelemwa & Mengo), Dr. Titus Beyeza (Chief Dept. of Orthopedics -Mulago), Dr. David Snell (anaesthesia registrar, Mengo), Dr. Sara Hodges (anaesthesiology, Mengo) To whom it may concern, The 2008 Uganda Spine Mission Team with gratitude and anticipation for the future, respectfully submit this trip report outlining the accomplishments and details of our recent Spine Surgery Mission. We would like to first acknowledge the support of the many, who with their contribution allowed us to once again accomplish so much. Synthes Inc. provided the full breadth of instruments and implants to allow us to treat the entire spectrum of spine pathology. Kyphon Inc. provided Health Volunteers Overseas with a charitable donation that covered travel and shipping related expenses for the team, as well as patient care related expenses such as the purchase of x-rays, CT scans, analgesic medications and antibiotic medications. The employees of Kyphon Inc. also raised a separate fund to help purchase a generator at some future date. Covidien Energy Based Devices donated a cautery unit and associated supplies. Mr Anibal Morales (CCF) was again resourceful in finding and refurbishing a discarded spinal surgery four-poster frame. Mr Tony Shawan (CCF) repaired and adapted the frame and other tools for our use. Ms Betty Balmat (CCF) and Dr Kris Siemionow (CCF) were instrumental in sourcing discarded linens (sheets, OR drapes, towels, gowns, pillow cases) at the Cleveland Clinic which were then packed and prepared by Mr Mark West's and Bob Gorta's (CCF) supply chain team for shipping to Uganda. Mr Rex Taylor sourced a head light generator, which was repaired for use. Ms Mary Kay Reinhardt (CCF) was instrumental in collecting discarded surgical supplies that were suitable for re-use. Medwish Inc. was yet again a source of vital medical equipment which proved indispensable during this mission. Finally, and as always, the staff at HVO and the staff at SRS were dedicated and a pleasure to deal with. The 2008 team consisted of the veterans (IHL & MK) and the rookies (SStC, AD, AR). There was a clear distinction in emotions and anticipation between the two. The veterans could not get off the planes fast enough to relieve their sore backs and necks, the rookies on the other hand to experience the mission. Once entrenched in the work flow, the entire team gained in their unique way an insight into their own personalities, their own beliefs and gained an appreciation for the devastation of neglected spinal pathology and the extent of care needed. By virtue of the previously mentioned generous support we were able to tackle all manners of spine pathology. We did however once again encounter our old limitation of time as well as new
frustrations. These included the lack of intra-operative x-ray facilities, mal-functioning sterilization units and a lack of fresh water for sterilization. In retrospect our "surgical egos" outmatched the available resources. Regardless, the prevalence of treatable spine pathology (neglected trauma, acute trauma, spinal infections, spinal tumors, spinal deformity and degenerative conditions) was excessive, and the need for comprehensive spine care, overwhelming. We stood tall to the task and persevered as is described below. Arrival (January 27th, 2008) After more than 17 hours of nonstop flying, the team arrived in Entebbe. Tired but not worn, the group piled into a van filled to the brim with luggage for an hour long trip to Kampala. With the windows lowered the cool fresh breeze, tinged with the smell of Lake Victoria proved quite rejuvenating. The group arrived at Mosa Court Apartments refreshed, and ready to unload the equipment and plan for the first day. Day 1 (January 28th, 2008) Our first day in Uganda started early, and began with a typical Ugandan breakfast that we would rapidly learn to appreciate. Notable items from the breakfast included passion fruit juice, fresh pineapple and watermelon, as well as Adam's favorite, Ugandan coffee. Once satiated, we packed the gear and headed out. The first stop was to get our U.S dollars exchanged to Ugandan schillings at a local foreign money exchange. After strategic haggling we found a place willing to sell us Ugandan shillings at 1700 per U.S dollar. Next, we headed to Old Mulago hospital, home of Makerere University's Department of Orthopedics, as well as what would soon become our second home. There we were warmly welcomed by the Head of the Orthopedics Department, Dr. Titus Beyeza, as well as Dr. David Denzel, a U.S trained physician who has been involved in mission work in Uganda for the past 15 years! Dr. Denzel talked to us briefly about the future of Orthopedics as well as the importance of Health Volunteers Overseas, and in particular the teaching and training to empower local surgeons to provide orthopaedic care. Dr. Titus Beyeza explained how recent efforts were underway to recruit more general surgeons to become Orthopedists as there was currently a substantial shortage within the country. Dr. Lieberman explained to Dr. Beyeza, Dr. Denzel, and the rest of the team that the Spine Mission had four main goals. The first was to understand the prevailing local conditions, the second to relieve anxiety concerning the longevity and sustainability of a mission, the third to grow and build the spine clinic for further missions and charitable endeavors, and fourth to participate in teaching and training the local health care practioners to provide spine care. After the stop in the office, Dr. Beyeza escorted the team to the newly constructed spine ward to not only view the progress but also to begin seeing patients. To the spine ward was attached a new structure outfitted to serve as an operating room, completely dedicated to spine cases. While it was still under construction, the level of excitement over all the potential possibilities was high.
Table 1 below outlines the patients seen on our initial clinic and ward rounds. (See also Table 4): Table 1: Old Mulago Spine Ward Patients (Seen on 01-28-08)
Name D.M B.N S.N Age 60 22 15 Sex F F F Diagnosis Complex C2 Dislocation T6-T7 Fracture/DislocationComplete Paraplegic Left-Sided Progressive Scoliosis (T7-L3) Thoraco/Lumbar apex at T12 Large Disc herniation C6-C7 Infective Spondylitis L5/S1 Pott's Disease (Spinal TB) Pott's Disease (T5-T6) L5/S1 Disc Herniation Lesion at T10-11 L4-L5 Disc Herniation Cervical Kyphosis Neurofibroma extending into C5-C6 Tenderness at L1 Epidural Abscess L4-L5 Discitis, osteomyelitis C5-C6 paraplegic T6-T7 Destructive Lesion C3/C4/C5/C6 Paraplegic L4-L5 Degenerative Stenosis Progressive Deformation (myositis ossificans progressiva) Kyphosis due to Pott's Disease Spondylolisthesis Treatment Treated with Traction No further surgical treatment Scoliosis Correction with Instrumentation Anterior Decompression and stabilization with instrumentation Anterior L5 corpectomy, decompression, and fusion Anti TB Medication to prevent bone growth Post-Op Patient Anterior Corpectomy and bone graft Decompression, Unilateral Laminotomy T11 Corpectomy, reconstruction, thorocotomy Decompression No further surgical intervention Laminectomy Performed No further surgical intervention Unilateral Laminotomy, Decompression, and Biopsy T4-T5 Posterior Laminotomy No further surgical intervention T6,T7 corpectomy, thoracotomy, decompression, and fusion Anterior decompression
45 26 29 47 45 36 20 29 21 44 27 40 22 40
9 10 45
No further surgical intervention recommended Correction of Kyphosis with instrumentation Post-Operative patient
Once the clinic and ward round were completed the team took some time and triaged the patients for surgery. The tentative plan for the first week would be to operate at Mulago hospital Tuesday and Thursday and Mengo hospital Wednesday and Friday. The following week we would operate at Mulago Tuesday and Thursday and Mengo Monday and Wednesday.
After visiting the patients at Old Mulago we traveled to the Uganda Cheshire home in Katalemwa. Uganda Cheshire Home is a privately funded orphanage, shelter, and school for poor and abandoned children. Here we split the team and began examining patients: Table 2: Katalemwa Cheshire Children's Home Patients (seen on 01-28-08)
Name I.M Age 13 Sex M Diagnosis Kyphosis secondary to Pott's Disease L5/S1 Spondyloptosis (Congenital Dislocation) Paraplegic Polio Epidural lipomatosis Destructive Sacral Lesion/L5 Lesion Torticollis Post-Operative follow up visit Treatment Anterior T4-T10 Corpectomies Posterior T4-L3 Instrument & Fusion Posterior/Anterior Reconstruction No further surgical treatment No further surgical treatment Posterior Right sided T3-T6 laminotomies and resection Sacral Biopsy No further surgical treatment No further surgical treatment
2 years 3 months 22 11 21 7 16 37
As Day 1 came to a close, a variety of emotions unpredictably bounced through each of us. Certainly from a logistical perspective the day was very busy as we saw over 40 patients, established treatment options, and scheduled many for surgery. Most of the patients we examined had succumbed to one of three spine related etiologies: motor vehicle accidents, infections (especially Pott's Disease/TB of the Spine), and congenital deformities. However, in between all of the ordered chaos, treatment discussion, and documentation, not one of us could ignore or deny the sights and sounds of what unfolded around us. The misfortune of patient A.F. was all but impossible to disregard. Akelu, as she was lovingly called by her grandfather and social worker, was a nine year old girl with a mangled body, who ostensibly had seen far too much pain in her short life. Due to the extensiveness of her deformities and the malignant volume of anomalous bone growth that progressively disfigured her, her case was deemed inoperable. This was crushing to her and her family especially considering the arduous journey from a distant village just to lose all hope (See Figure 1).
Figure 1- Patient A.F, 9 year old female with Myositis Ossificans Progressiva
Even with unfathomably discouraging moments came other encounters that quickly reminded the team of the immense benefit that could improve the lives of others. Patient S.L arrived unannounced at the Katalemwa clinic. He had surgery in 2006 (see Trip report June 2006) to repair injuries sustained in a devastating industrial accident. After being paralyzed and bed ridden for months with a spine fracture, the surgery allowed him to walk into the clinic of his own accord. He appeared in great shape and was so thankful to Drs. Lieberman and Kayanja for restoring much of his function. He had clearly recovered enough function to truly have a new lease on life (See Figure 2).
Figure 2; Patient S.L., 2 year follow up, stable spine, able to walk, Lt to Rt Lieberman, Patient S.L. Kayanja This first day foreshadowed the intensity of highs and lows that the team would experience and really set the tone for the level of impact that could be made by the team's presence. The team headed back to Mosa Court for what would be the first of many late night dinners. Day 2 (January 29th 2008) Day two was the first day of surgery at Old Mulago. Four surgeries were tentatively scheduled: Patients L.O, M.B, C.O, and T.G. Disappointingly only two surgeries were completed due to lack of water, which was needed to run the autoclave for sterilization of the surgical tools. This lesson reaffirmed the adage of planning for the unexpected. Thus the surgeries of patient M.B and patient T.G were postponed and the surgeries of L.O and C.O were completed. Patient L.O was a forty-five year old man who unfortunately had been suffering for more than eight years with longstanding back pain that seemed to radiate into his gluteal region. He also suffered from a loss of muscle strength rendering him bed ridden. Based on a less than ideal quality CT scan which revealed an ill defined epidural mass lesion we had recommended a decompression operation. At surgery a massive extruded disc fragment was discovered and
evacuated. Post-operatively, patient L.O did exceedingly well and by day three (January 30th, 2008) he had a self reported significant reduction in pain, and very shortly there after regained sensation in his legs. By day 5 (February, 1st, 2008) patient L.O could not be found in the spine ward. Much to our surprise we found him walking about outside, in quite a good mood. His smile conveyed his gratitude (see Figure 3).
Figure 3- Outside Old Mulago Spine Ward. Standing (L to R) Dr. Mark Kayanja, Dr. Titus Beyeza, Dr. Isador Lieberman, Patient L.O., Bharath Surapaneni Patient C.O was a 45 year old woman suffering from progressively debilitating lower back pain over a two week period. She was presumed to have infective osteomyelitis / discitis of her L5/S1 region exacerbated by her immuno-compromised state (HIV+) and TB infection. Her corrective procedure would be an anterior L5 corpectomy, decompression, reconstruction and fusion. Post-operatively she reported less back pain and only slight abdominal pain, probably due in part to her anterior abdominal incision. By day 10 (February 6th, 2008), she reported increased sensation and a feeling of heaviness in her legs. She was started on anti-TB medication on confirmation of her culture results (See Figure 4).
Figure 4- Smiles All Around. (L to R) Dr. Selvon St.Clair, Patient C.O, Dr. Isador Lieberman
Later that day the surgical supplies arrived. They had previously been held up in Entebbe and were now waiting to be moved into the OR. Once they saw the piles upon piles of linens and tools that just flooded the tiny hall of the Old Mulago operating room, Dr. Nyati and the operating room staff were all particularly pleased to see the new supplies. (See Figure 5)
Figure 5-Arrival of Surgical Supplies. (L) Dr. Titus Beyeza oversees supplies (R) Supplies fill narrow hall of Mulago OR. Day 3 (January 30th, 2008) Today would be the first day of surgery at Mengo hospital operating theatre which was without a doubt more organized and newer than the operating room at Old Mulago. After a brief stop at Old Mulago to check on the post-operative patients the team made its way to Mengo. There, Dr. Lieberman reassured the team that though we only completed two out of four surgeries yesterday at Old Mulago, treating those two patients with the limited resources at hand was still beneficial and far more cost effective than surgery on a single patient in the U.S. The surgeries scheduled for Mengo were those of patients E.A and A.N. Patient E.A was an adorable three year old girl with a congenital kyphosis. Her corrective procedures involved an anterior release of (T10-11, T11-12) as well as a posterior release and fusion of (T9-L1). Her surgeries took place in two parts (January 30th and February 6th 2008). Her post-operative course was unremarkable. She had steadily improved (See Figure 6) and was discharged after we had left Uganda.
Figure 6- Patient E.A, first seen at Katalemwa Cheshire Children's Home, Post-Op (1/30/08)
Patient A.N was a seventeen year old female with progressive idiopathic scoliosis. Her corrective procedure was to be done in two parts. First would be a right anterior release (T4T11) followed later by a posterior correction, fusion and instrumentation (See Figure 7). Her right sided anterior release was performed on January 30th 2008, without any adverse events. On February 1st, 2008 at around 7:00 PM as the team was loading up the van with supplies, the anesthetist David Snell discovered A.N to be in significant respiratory distress. Her breathing was labored and clinically it appeared that her chest had filled with fluid due to mal-function of the chest tube. We used intercostal blocks to relieve her pain and further drained her chest in the hopes of her being able to cough up any remaining mucus plugs in her airways. She did not improve with these maneuvers and progressively deteriorated. We then re-intubated her, and it became clear that we were reaching the limited capacity for treatment at Mengo and that A.N would need to be mechanically ventilated. Unfortunately we were unable to initially find a place with a ventilator to accept her. As such we elected to manually ventilate her through the first night. The following day we were able to negotiate a bed and ambulance transfer to the International Hospital of Kampala (a private hospital with ventilator support). Dr. St.Clair, along with the anesthetic team of Dr. Sara Hodges, David Snell, and Maria Aguti, accompanied patient A.N to IHK (International Hospital Kampala) ICU at 11:00 AM on Saturday February 2nd, 2008 (Day 6). Once there, an x-ray confirmed complete collapse of her left lung. The team attempted with only little success to evacuate any bronchial obstruction and mucus plugs, using a reclaimed bronchoscope. We decided to continue as best as possible with chest physical therapy, ventilation and anti-biotics to support A.N. Due to minimal improvement, a tracheostomy was recommended and performed on Sunday February 3rd, 2008. This proved to be the turning point for her as now she began to improve. By February 7th 2008, it was reported by physiotherapy staff that A.N was cooperating with breathing exercises. As of February 28th, 2008 it was reported that patient A.N was progressing well and was up and walking. The experience with A.N. reminded the team just how fragile the situation could be, just how important proper imaging and equipment are, and the resilience of the human spirit. We were unable to complete the posterior correction and fusion.
Figure 7-(L) Patient A.N, first seen at Katalemwa Children's Home (R) Patient A.N's collapsed Left Lung
Day 4 (January 31st 2008) This would be the second day of surgery at Old Mulago and meant to be the most ambitious. We had scheduled six surgeries. Much to our chagrin, as we started the first two cases in separate operating rooms, we were advised that the autoclave once again ran out of water. We did still manage to complete four surgeries, those of patients S.N, S.L, M.I, and T.G. Patient S.N was a fifteen year old female with left sided progressive scoliosis (thoracic kyphoscoliosis) whose corrective procedure would take place in two parts (See Figure 8). The first procedure involved anterior multi-level releases and took place on January 31st, while the posterior correction, fusion instrumentation procedures were scheduled for February 5th 2008 (Day 9). After patient S.N's first procedure, she entered recovery at the Old Mulago spine ward where she was placed in 30⁰ gravity traction and monitored closely. By February 5th, it was clear that S.N was strong enough and eager to begin her second procedure. After her second procedure, patient S.N was transferred to New Mulago ICU where she remained stable overnight. Quite memorably, when visiting patient S.N at New Mulago the day after her 2nd surgery the only thing she requested of us was an Orange Fanta!
Figure 8- Patient S.N, (L to R) Intake, X-ray showing L sided scoliosis, and 30⁰ gravity traction Patient S.L was a forty-six year old male suffering from lower back pain and leg weakness. On the basis of his history, clinical findings and investigations he was presumed to have L4-L5 discitis and osteomyelitis with an epidural abscess. This required debridement through a posterior decompression. After surgery, S.L quickly regained sensation in his lower extremities and reported increasingly less pain in the days following surgery. Patient M.I was a fifty seven year old retired general practitioner suffering from lower back pain, loss of muscle strength in his lower extremities, and problems with finely coordinated tasks all sustained from a motor vehicle accident in 1996. After the accident, patient M.I was unable to walk but slowly over one year gained that ability with a cane for added support. Investigations revealed multiple level cervical degeneration with prolapsed discs. The culprit level was estimated to be C3-C4, although the other levels were degenerate and stenotic as well. It was also determined that patient M.I may be suffering from degenerative spinal stenosis at the lumbar L4-L5 level, perhaps intensifying his symptoms. He was scheduled for an anterior multi-level decompression and fusion of the cervical spondylosis. Due to lack of appropriate imaging at the time of surgery, it became difficult to precisely identify the correct cervical levels and thus a second revision surgery was scheduled for February 5th, once adequate post-op
imaging was reviewed (See Figure 9). After his second procedure, patient M.I reported some initial improvement of his pain, although he still felt weakness in his arms and legs. On final review we recommended he pursue physical therapy to improve his strength.
Figure 9- Patient M.I, X-rays taken (February 1st, 2008) after 1st procedure. Patient T.G was a twenty seven year old male paralyzed from the waist down, with loss of bowel and bladder function. He was presumed to have an epidural abscess at the T4-T5 level, requiring a unilateral laminotomy, decompression, and biopsy (See Figure 10). After the procedure, patient T.G reported new sensations in his right leg, specifically burning and tingling. Although T.G was still unable to wiggle his toes or move his lower extremities, his report of paraesthesia was encouraging. His subsequent biopsy report was negative.
Figure 10- Patient T.G, CT Scan and x-ray indicating possible epidural abscess. In addition to making sure we were always properly fed and caffeinated, the dedicated nursing and support staff of both Mulago and Mengo hospital were tireless in their work ethic, deep in their compassion, and always light hearted. Rather than dismiss the team as a group of outsiders, they exceeded all expectations in efforts to not only get to know us, but also to make us feel as one of their own. Every morning, Sister Emmy's warm greeting really provided the team an extra kick start for the day (See Figure 11).
Figure 11- (L to R) Old Mulago Support Staff, Delicious Ugandan Lunch, and Sister Emmy
Day 5 (February 1st, 2008) Day five marked a return to the Mengo Hospital for surgeries on patients H.K and A.Y. Patient H.K was a five year old girl who suffered from a congenital dislocation (spondyloptosis) of L5/S1. This required a whole day of surgery including a posterior release of levels L4/L5/S1, anterior release of L5/S1, and a posterior fusion of levels L3-S1. After surgery H.K entered recovery at C.O.R.U (Children's Orthopedic Rehabilitation Unit) and by the next day she was recovering well with stable vital signs. She remained neurologically intact with movement in her legs, and her mother reported that she was experiencing mild pain in her back. By February 7th, H.K appeared very well, was smiling, and playing intently with her doll and stuffed animals (See Figure 12). Patient A.Y was a thirty-five year old cachectic male who was suffering from disabling, chronic lower back pain and reduced muscle strength and sensation in his lower limbs. His investigations revealed an L1 osteolytic (bone destroying) fracture presumably due to osteomyelitis (bone infection). This was addressed by a posterior L1 exposure, decompression, biopsy and reconstruction. During surgery we were suspicious of the presumed diagnosis, now favoring some sort of tumor. The day after surgery, patient A.Y reported feeling much better and that he had less pain. In addition, he began to regain sensation in his left thigh to the knee. Before surgery he had no sensation in his left leg. By February 7th, A.Y appeared tired but in no apparent distress. The biopsy result from the sample taken at the time of surgery confirmed our suspicion of cancer with a diagnosis of adenocarcinoma, possibly of lung origin. He was eventually transferred to Mulago Hospital for an oncology consultation.
Figure 12- (L to R) Patient H.K Post-Op, Pre-Op X-ray, Post-op X-ray Day 8 (February 4th, 2008) Three pediatric operations were scheduled at Mengo hospital for day eight. By the time the surgeries of patients N.L and F.B were completed, it was mid-afternoon and thus the third scheduled surgery, the surgery of patient K.J, would need to be postponed until the next mission. Patient N.L was a thirteen year old paraplegic girl whose spinal deformity formed a sharp bump in her lumbar region which prevented her from sitting comfortably (See Figure 13). She was diagnosed with Pott's disease (Tuberculosis of the Spine) at the L2/L3 level, requiring an anterior release/reconstruction as well as a posterior instrumentation procedure. N.L's deformity was remarkable for the fact that it left her spinal cord vulnerable to injury due to the complete destruction of the posterior vertebral elements. This deformed configuration of her spinal cord clearly played a major role in the development of her paraplegia. After her surgery, N.L's back was visibly much straighter and what remained of her massive bump was now flat.
She still lacked the ability to move her toes or legs but appeared generally well with no complaints of pain. Patient F.B was a seven year old girl with a destructive sacral lesion that appeared to be pathologic, for which we recommended a right sided open posterior alar biopsy. Based on her available imaging, it appeared that F.B might have an eosinophilic granuloma (benign typically childhood tumor, See Figure 14). However, the differential pathologic diagnoses also included osteosarcoma, chondroma, or Ewing's sarcoma. After surgery, F.B's incision healed quickly and she was started on antibiotics as the tissue taken for biopsy was more consistent with infection than tumor. The pathology and microbiology results at 48 hours were inconclusive.
Figure 13- (L to R) Patient N.L positioned for surgery (Top-Anterior), Pre-Op & Post-Op X-Ray
Figure 14-Patient F.B (Pathologic Sacral Lesion) CT Scans Day 9 (February 5, 2008) Today took the team back to Old Mulago for the revision surgery of patient M.I and the second part of patient S.N's scoliosis correction. Two other patients were also originally scheduled for this day including patients F.N and R.K. Both were ultimately postponed due to uncontrolled hypertension and diabetes. After S.N's surgery, she was transported to New Mulago ICU where she remained stable overnight. By February 6th, she was neurologically intact, with stable vitals and we had removed her chest tube. After patient M.I's revision surgery he reported feeling much better but still had weakness in his legs and less flexibility in his left arm.
In addition to the flavorful breakfast jam each morning the team often tasted a "jam" of a different kind. The traffic jams in Kampala were epic. At times, even impassable, and it certainly made operating a tight schedule very difficult. The road conditions were likewise troublesome (See Figure 15). We did have the luxury of an experienced driver. Alex had become quite resourceful at getting us through the melee at breakneck speeds so that we could manage the daily responsibilities at multiple hospitals. It also helped that the team divided up to visit each hospital early in the mornings allowing time to return to join the other half in surgery before rush hour hit.
Figure 15-(L to R) Kampala Traffic, Roads with canyon-like potholes
Day 10 (February 6, 2008) Three surgeries were scheduled for Day 10 although only two were completed. Patient I.M unfortunately contracted malaria only a few days before his scheduled operation and thus would require a round of treatment with chloroquine prior to an operation. The other scheduled patients for surgery, E.E. and E.A. were completed. The procedure for E.A was the second part of her scoliosis correction. The first part of the correction took place on January 30th (Day 3), and involved the anterior release of levels (T10-11, T11-12). This day's procedure would be the posterior release and fusion of (T9-T11). She did well post surgery with no adverse issues affecting her recovery. Patient E.E. was a twenty year old male who quite suddenly lost the ability to walk about three years prior. He had no sensation in his lower limbs but had maintained bowel and bladder functioning. From imaging it was presumed that he may have an epidural lipomatosis (See Figure 16). His procedure would be a posterior right sided (T3-T6) laminotomy and resection. One day after his surgery, E.E. still had tremors and clonus. Two days after surgery, quite remarkably, he could move his toes as well as his knees and appeared to have no tremors or clonus (involuntary muscle contraction) which was very promising. Nevertheless, there was still no biopsy report available at the time.
Figure 16- Patient E.E (L to R) CT myelogram indicates extra-dural tissue with features common to extra-dural neoplasm, lymphoma, metastatic disease, or lipomatosis. Day 11 (February 7, 2008) Our final day of scheduled surgery would take place at Old Mulago, right where we started. Four surgeries were again scheduled; patients M.A, F.N, A.G, and R.M. Due to multiple reasons including lack of anaesthetic coverage and a very late start, only the surgeries of A.G and R.M were completed. Patient R.M was a thirty five year old female who was diagnosed with a unilateral facet dislocation at the C4/C5 level. This was treated with a posterior reduction and stabilization procedure. Post operatively she reported improvement in her neck pain. The final patient A.G was a twenty-five year old female suffering from complete C5 level paraplegia. She was in a car accident on January 17th, 2008. Her investigations revealed a large disc herniation at the C6-C7 level. We proceeded with an anterior discectomy and fusion. Once again we did not have any intra-operative x-ray capability to help verify the level. Despite an extensive exposure the wrong level was decompressed. This was not confirmed until the morning of our departure as we could still not get x-rays done immediately after surgery. The entire team was devastated as we all felt this was one patient we could have possibly helped. Day 12 (February 8, 2008) Our last day in Uganda started off at Old Mulago where Dr. Selvon St. Clair and Dr. Mark Kayanja presented didactic lectures to the department of Orthopedics. Later, the team went to Mengo and IHK to check on all of the patients. Dr. St. Clair presented a lecture entitled "Surgical Exposures of the Thoracic and Lumbar Spine". He covered anterior, posterolateral, and posterior approaches including the transthoracic, thoraco-abdominal, costostransversectomy, flank retroperitoneal approach, and trans-peritoneal approach. The key point of the lecture was that the approach chosen should match the patient's pathology to minimize healing time and to avoid complications. Dr. Mark Kayanja presented a lecture entitled "Spine Biomechanics" that covered many important central concepts in spine biomechanics such as "load to failure" which occurs when a loads exceed the load bearing capability of the spine. He also explained that the spine is exposed to forces and displacements and that in response, the spine answers by allowing or limiting movement. Transitional areas of the spine, the cervico-thoracic junction and the thoraco-lumbar junction, are vulnerable and bear relatively greater biomechanical stress. This
increased biomechanical stress often leads to injury in these areas. Also, within the structure of vertebral bone there are horizontal and vertical ties and both elements are critical to the force bearing nature of vertebra. Thus when there are conditions that compromise the regular vertical/horizontal matrix, such as osteoporosis or tumor infiltration, injury can occur. During the lecture, Dr. Titus Beyeza asked whether the lifestyles of Ugandan women, especially the repeated activities such as farming, dancing, and cooking could predispose them to stress injuries of the facet joints and thus to spondylolisthesis (slipped vertebral body). Dr. Lieberman responded with an example of how lifestyle can definitely affect the demographics as well as injury profile of a population. He went on to describe his observations while traveling through Nepal with the Sherpas. There he noticed a paucity of men over the age of fifty-five but plenty of women of this age or older. He didn't understand why until he visited the local hospital. Since many of the Sherpas work as porters, their livelihood involves carrying heavy parcels on their backs supported by a strap around their foreheads. Because of this repeated stress on cervical spine they are predisposed to cervical spondylosis (degenerative arthritis) and myelopathy (compression of the spinal cord leading to gait disturbance and imbalance while walking). Due to the myelopathy they fall while working either breaking their necks or breaking their femurs (thigh bone) which are both life threatening injuries from which many do not recover. After the lectures, exchanges of thanks were made by both Dr. Titus Beyeza and Dr. Lieberman (See Figure 17)
Figure 17- (L to R) Spine team and Mulago Dept. of Orthopedics group pictures
Epilogue; Bharath Surapaneni When reading the daily newspaper while stuck in a "jam", I came across a quote that our driver Alex had explained to me. After his explanation I thought about it quite a bit and tried to reflect on what it really means. In Uganda, the saying "Omulya mamba aba omu navumaganya ekika" means that one man's sin reflects not only himself but also on all of his people. I came to realize though, that if this is true then the converse must also be true, which is, that one man's goodwill must also reflect not only on himself but also on all of his people. Therefore in terms of the spine mission, the work of the spine team was not an isolated event to be lost or forgotten, but really a reflection on all of our intrinsic capacity, our capacity as health care workers and members of society to help heal and comfort, to teach and cultivate, and to create and inspire. And so, by planting the seeds of goodwill today, we will certainly ensure the continued forest of goodwill and reciprocity tomorrow. Epilogue; Selvon St. Clair This was my first trip with the Uganda Spine Surgical Mission and undoubtedly will not be the last. Even though fore warned by both Drs. Lieberman and Kayanja, I was still astounded by the relentless varied spine pathology and the lack of basic medical resources to adequately treat patients in Uganda. Throughout the fortnight, I was constantly reminded of my favorite Einstein quote : "only a life lived for others is worth living". For the first time in my career I fully understood what it meant to live for others and contribute selflessly towards the human condition. I quickly realized how much good can be done with so little. Although we were constantly frustrated by the lack of resources and overall logistical difficulties, our mere presence was sincerely appreciated by all. I was especially touched when one of the orthopaedic surgeons walked up to me and said, "thanks for helping Ugandans". However, at the end of the trip, I was very saddened by our failures, which left an indelible impression on me and a burning desire to continue to partake in this and other global surgical spine missions. Epilogue; Adam Rodatt After participating in the Uganda mission 08' trip, the reward of helping others is beyond description. One can never be completely prepared to tackle the medically challenged in a different part of the world, away from our highly technical society. Simple things, such as paper towels, trash receptacles, electrical extension cords, and water were not readily available and we had to re-educate ourselves to be without. The positive energy that radiated from the team was just as powerful as our surgical skills with the families, patients, and hospital staff. We adapted quickly and adjusted as problem solvers to the simplicity. This mission was only the beginning, more will follow, as education is addicting to all that is touched. As a nursing professional and colleague, it truly was an honor to assist the surgeons involved and a privilege to be part of this mission. Epilogue; Mark Kayanja Returning to Uganda for the 3rd Spine Mission was a trip down memory lane. The problems that we encountered were reminiscent of what had collectively created an urge in me to try to advocate for change. Problems like lack of intra-operative X-rays, water shortages infiltrating surgical lists, neglected spinal pathology served as fuel to my drive and commitment to the Uganda Spine Mission. With all the great support and commitment from the people involved in the mission I believe there has been an impact on the lives of several Ugandans. I look forward to the mission growing and blossoming as we head into the future. I say "Gakyali mabaga," the motto from my High school in Uganda which means there is plenty of work ahead!
Epilogue; Isador Lieberman After two very successful missions to Uganda I returned with a strong team (see Figure 18), plenty of equipment, far less anxiety and an invincible outlook. By the end of the mission it was clear that my surgical ego outmatched the environment and resources. Having seen more patients this trip than in the past, having triaged many more severe cases, I directed the team to take on more than we realistically could have. We left behind many disappointed patients and families for whom which, we simply ran out of time. The lack of ICU facilities and intra-operative x-rays frustrated me beyond any frustration I had ever experienced as a surgeon. In retrospect I did inflict on three patients more than I can now justify, with limited if any benefit. These lessons are tattooed on my mind. I can only hope this will in some way help others.
Figure 18 – Dr St Clair, Dr Kayanja and Mr Surapaneni
Table 3; 2008 Surgical Cases
Date 1/29/2008 1/29/2008 Name L.O C.O Age 45 49 Sex M F Diagnosis L4/5, L5/S1 Disc Herniation Infective Spondylitis L5/S1 Procedure Decompression L5 Corpectomy Decompression Fusion Anterior Release T10-T11, T11-T12 and corpectomy of T10 Right anterior release T4-T11 Anterior Thoracotomy, Release of T10/T11, T11/T12, T12/L1 Posterior Decompression L45 C/4/5/6 Anterior Release Unilateral Laminotomy Decompression, Biopsy T4/T5 Anterior Release L1-L4, Posterior Release L4/L5/S1 and fusion L3-S1 Posterior Release L1 Anterior Release and Reconstruction and Posterior Instrumentation Alar Open Biopsy C3/C4 Anterior Decompression and Fusion Scoliosis Correction with Instrumentation Posterior Rt Sided (T3-T6) HemiLaminotomies and Resection Posterior release and fusion Anterior Decompression and Stabilization C6/C7 Corpectomy Reduction and Stabilization C4/C5 Unilateral Reduction and Fusion
1/30/2008 1/30/2008 1/31/2008 1/31/2008 1/31/2008 1/31/2008
3 18 15 46 57 27
Scoliosis Scoliosis Left Sided Progressive Scoliosis L4-L5 Discitis L4-L5 Degenerative Stenosis + C4/C5, C5/C6 Epidural Abscess
2/1/2008 2/1/2008 2/4/2008 2/4/2008 2/5/2008 2/5/2008 2/6/2008 2/6/2008 2/7/2008
5 35 13 7 57 15 20 3 25
Congenital Dislocation L5/S1 L1 Fracture/Osteomyelitis Pott's Disease (TB of the Spine) Destructive Sacral Lesion Prolapsed Discs C3/C4, C4/C5 Thoracic Kyphoscoliosis T7L3 Epidural Lipomatosis Scoliosis C6/C7 Disc Herniation
Unifacet Dislocation C4/C5
Table 4- 2008 Patient List (CCHK-Cheshire Children's Home Katalemwa) Age Cat. Name Date Location Symptoms (Sex) neck pain Old after car I.P D.M 60(M) 1/28/2008 accident Mulago I.P I.P I.P I.P I.P I.P I.P I.P I.P B.N S.N A.G C.O N N.S K.M O.L D.B 22(F) 15(F) 25(F) 45(F) 26(F) 29(F) 47(F) 45(M) 36(M) 1/28/2008 1/28/2008 1/28/2008 1/28/2008 1/28/2008 1/28/2008 1/28/2008 1/28/2008 1/28/2008 Old Mulago Old Mulago Old Mulago Old Mulago Old Mulago Old Mulago Old Mulago Old Mulago Old Mulago Old Mulago Old Mulago Old Mulago Old Mulago Old Mulago Old Mulago Old Mulago Old Mulago Complete Paraplegic Progressive Curvature Complete Paraplegic Lower Back Pain (HIV+) Lower Back Pain Lower Back Pain Lower Back Pain Loss of strength in lower limbs Progressive Pain Low Back Pain, Lower Limb Weakness HyperReflexive on Left Side Decreased Strength in Lower limbs Low Back Pain, Lower Limb Weakness Loss of bowel and bladder function Low Back Pain, Lower Limb Weakness Loss of power in lower limbs, Pressure Sores Paraplegic Dragging legs, tremors, loss of sensation in fingertips
Diagnosis Complex C2 Dislocation T6-T7 Fracture/Disloc ation Left-sided Progressive Scoliosis Large Disc Herniation C6C7 Infective Spondylitis L5/S1 Pott's Disease (TB of the Spine) Pott's Disease (TB of the Spine)
Treatment Treated with traction No further Treatment Scoliosis Correction Anterior Decompression and Stabilization L5 Corpectomy, Decompression, Fusion Anti-TB Medication to prevent bone growth Post-Operative Anterior Corpectomy and bone graft Decompression T11 Corpectomy, Thorocotomy
Disc Herniation L4/5, L5/S1 Lesion @ T10T11 L4-L5 Disc Herniation Cervical Kyphosis neurofibroma extending into C5-C6 Tenderness at L1 Pott's Disease (TB of the Spine) L4-L5 Osteomyelitis Previous C5-C6 Fracture T6-T7 Fracture/Disloc ation Prolapsed Discs (C3,C4,C5,C6) L4-L5 Stenosis (Degenerative) Myositis Ossificans Progressiva, Anomalous Bone
1/28/2008 1/28/2008 1/28/2008
Decompression No further Treatment Received Laminectomy Post-Op
1/28/2008 1/28/2008
No further Treatment Unilateral Laminotomy Decompression, Biopsy T4-T5 Posterior Decompression Laminotomy
1/28/2008 1/28/2008
No further Treatment T6-T7 Corpectomy, Biopsy Required
Old Mulago
Anterior Decompression and Fusion (C3/C4)
Old Mulago
Trouble Breathing
Unable to Provide Treatment
Old Mulago Old Mulago Old Mulago
1/28/2008 1/28/2008
Back Swelling, Pain in the legs, cannot stand PostOperative complaints of pain Paraparesis Lower back pain, reduced strength and sensation in lower limbs
Pott's Disease (TB of the Spine) L5-S1 Spondylolisthes is C5/C6 Spinal Cord Compression
Stabilize Spine (Anterior/Posterior Approach)
CT myelogram for review C5/C6 Corpectomy and Fusion
1/28/2008 1/28/2008
Old Mulago Old Mulago Old Mulago CCHK
Spinal Stenosis L4/L5, L5/S1 Cervical Spondylosis Unifacet Dislocation
1/28/2008 1/28/2008
Right sided Laminotomy B/L Decompression Anterior Decompression and Fusion (C3/C4) and (C4/C5) Reduction and Stabilization C4/C5 Unilateral Reduction and Fusion Plain x-ray requested prior to further work up.
1/28/208 1/28/2008
Increasing pain in her neck PostOperative complaints of pain
1/28/2008 1/28/2008
Trouble Breathing Paraplegic has no sensation/moti on in lower limbs. Lower limb discrepancy, scoliosis No sensation in lower limbs, weakness in legs. Left curve scoliosis
Pott's Disease, Kyphosis Spondyloptosis L5/S1
No further Treatment Anterior Release (T10-11, T11-12) Posterior Release + Fusion (T9-L1) Anterior T4-T10 Corpectomies/reconstructi on, Posterior T4-L3 instrumentation and Fusion Posterior/Anterior Reconstruction Unlikely to regain sensation with surgery since time since accident has been 4 years.
Polio (Characteristic gait and scoliosis) Neurological Scoliosis (Epidural Lipoma) Congenital dislocation L5/S1 Spondyloptosis L1 Fracture/Osteo myelitis/Adenoc arcinoma Pott's Disease (TB of the Spine) Destructive Sacral Lesion Posterior Right Sided Laminotomies T3-T6 and resection Posterior release L4/L5/S1 → anterior release L5/S1 → posterior L3-S1 fusion
CCHK Lower back pain, reduced strength and sensation in lower limbs Paraplegic, difficulty sitting due to deformity Sacral Deformity
Mengo Hospital
1/28/2008 1/28/2008
Posterior Release L1, fusion Anterior Release/Reconstruction and posterior Instrumentation Alar Open Biopsy
1/29/2008 1/29/2008
Mengo Hospital Mengo Hospital Mengo Hospital
Kyphosis Progressive Curvature
T4-L2 Kyphosis Prog. Idiopathic Scoliosis Pott's Disease (TB of the Spine) T8-T9
Posterior Correction with Instrumentation Right Anterior Release (T4-T11) Anterior Release/Reconstruction and posterior Instrumentation


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text: Metro Vancouver Real Estate Login with: Forgot password Extend Verify Contact Signup Login 1412 VICTORIA Drive Grandview VE Vancouver V5L 4G9 $1,189,000 Residential Detached beds: 3 baths: 2.0 1,902 sq. ft. built: 1912 Share on Twitter Share on Facebook Share on Google+ Share on Pinterest Share Link Share on Twitter Share on Facebook Share on Google+ Share on Pinterest Share Link Details Photos Map Status:Active Prop. Type:Residential Detached MLS® Num:R2340243 Bedrooms:3 Bathrooms:2 Year Built:1912 Photos (20) Contact about details Send listing Mortgage calculator Print listing Local places Solid bungalow with 2 self-contained suites, across from Victoria Park, in prime Commercial Drive location! Bright main level has a 2 bedroom suite with an open living/dining room overlooking the park, and an updated kitchen with access to the back deck. Lower level has a 1 bedroom suite with great height with its own laundry and patio. Over 400 sqft of unfinished space awaiting your design ideas or great for storage! Nice little back yard with fruit trees. Easy walk to all the vibrant amenities Commercial Drive has to offer – schools, parks, cafes, shopping, markets, transit & more. Come be a part of a connected, walkable community with a bright future! Open House Sunday 12-1 General Info: Property Type: Residential Detached Dwelling Type: House/Single Family Year built: 1912 (Age: 107) Total area: 1,902 sq. ft.176.7 m2 Total Floor Area: 1,902 sq. ft.176.7 m2 Main Floor Area: 916 sq. ft.85.1 m2 Finished Levels: 2.0 Bedrooms: 3 (Above Grd: 3) Bathrooms: 2.0 (Full:2/Half:0) Taxes: $3,900.6 / 2018 Lot Area: 2,508 sq. ft.233 m2 Lot Frontage: 38'11.582 m Lot Depth: 66 Plan: VAP4103A Additional Info: Basement: Partly Finished, Separate Entry Fireplaces: 1 Title to Land: Freehold NonStrata Site Influences: Central Location, Recreation Nearby, Shopping Nearby View: Victoria Park Photo 1 of 20 Photo 2 of 20 Photo 3 of 20 Photo 4 of 20 Photo 5 of 20 Photo 6 of 20 Photo 7 of 20 Photo 8 of 20 Photo 9 of 20 Photo 10 of 20 Photo 11 of 20 Photo 12 of 20 Photo 13 of 20 Photo 14 of 20 Photo 15 of 20 Photo 16 of 20 Photo 17 of 20 Photo 18 of 20 Photo 19 of 20 Photo 20 of 20 Larger map options: Larger map Street View Walkscore Listed by Stilhavn Real Estate Services Listing information last updated on February 14, 2019 at 08:12 PM (UTC) Area Statistics Listings on market: 51 Avg list price: $2,188,000 Min list price: $988,000 Max list price: $4,288,000 Avg days on market: 100 Min days on market: 2 Max days on market: 668 Avg price per sq.ft.: $939.91 These statistics are generated based on the current listing's property type and located in Grandview VE. Average values are derived using median calculations. Get market change alerts Jordy Brisbin Sutton-Centre Realty 604-839-2891 Contact by Email The data relating to real estate on this website comes in part from the MLS® Reciprocity program of either the Real Estate Board of Greater Vancouver (REBGV), the Fraser Valley Real Estate Board (FVREB) or the Chilliwack and District Real Estate Board (CADREB). Real estate listings held by participating real estate firms are marked with the MLS® logo and detailed information about the listing includes the name of the listing agent. This representation is based in whole or part on data generated by either the REBGV, the FVREB or the CADREB which assumes no responsibility for its accuracy. The materials contained on this page may not be reproduced without the express written consent of either the REBGV, the FVREB or the CADREB. powered by myRealPage.com


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ADDRESS:Fenlukou Town Yu'an District Lu'an City Anhui China-237143
The purpose of refining outside the furnace is to degas, deoxidize, desulfurize, remove inclusions, fine tune the composition and control the temperature of the molten steel to obtain the high quality molten steel required for continuous casting. In this process, refractory materials have a certain influence on the quality of molten steel.
At the time of selection, we must consider the temperature of the molten steel, stirring, treatment time, vacuum, arc heating, refined steel grade, the nature of the slag, the alkalinity of the slag, the fluidity of the slag, etc. .
Magnesia chrome brick
Magnesia-chrome brick is an alkaline refractory material mainly composed of magnesia and chrome ore. Magnesia-chrome brick has the characteristics of high refractoriness, high load softening temperature, good thermal shock resistance, strong resistance to slag erosion, and wide range of alkalinity of slag. According to different raw materials and process characteristics can be divided into:
1 silicate combined with magnesia chrome brick
The sintered magnesia and the general refractory grade chrome ore are used as raw materials, and are mixed in an appropriate ratio, and the sulfite pulp waste liquid is used as a binder, kneaded and formed, and fired at 1600 ° C.
Typical physical and chemical indicators of silicate combined with magnesia chrome brick
2 directly combine with magnesia chrome bricks. High-purity magnesia and chrome ore are used as raw materials, high-pressure molding, and fired at 1700~1800 °C to produce high-quality solid-phase combined magnesia-chrome bricks.
Typical physical and chemical indicators of several direct combination of magnesia chrome bricks
3 combined with magnesia chrome bricks (electrofusion combined with magnesia chrome bricks). Using magnesite (or light burnt magnesium powder) and chrome ore as raw materials, according to a certain proportion, into the electric furnace to melt, synthesizing fused magnesia chrome frit, then crushing, mixing, high pressure molding, burning at 1750 ° C or higher Made into.
4 and a half combined with magnesia chrome bricks. Partially fused synthetic magnesium chrome sand is used as raw material, and part of chrome ore and magnesia or sintered synthetic magnesium chrome are added as fine powder, which is prepared by high temperature firing according to conventional brick making process.
The product has compact structure, low porosity, high temperature strength, strong erosion resistance, thermal shock resistance better than recombined magnesia chrome brick, RH and DH vacuum degassing dip tube, VOD furnace, LF furnace, AOD furnace. The slag line of the refining equipment outside the furnace.
5 pre-reactive magnesia chrome bricks. Light calcined magnesium powder and chromite ore are used as raw materials, and finely ground into fine powder with a particle size of less than 0.088mm, pressed into a blank or ball, calcined into a pre-reacted sintered material at 1750-1900 °C, and then pressed into a conventional brick making process. Production, crushing, mixing, high pressure molding and firing at 1600~1780 °C.
The product has compact structure, uniform composition, low porosity, high temperature strength, good slag resistance and good thermal shock resistance, and can be used for slag line parts of refining equipment such as VOD furnace, LF, furnace and the like. The national standards for magnesia chrome bricks are shown in Table 4.
Magnesium chrome brick physical and chemical indicators
2. MgO-CaO refractory
1 dolomite brick
An alkaline refractory material containing W(CaO)>40% and w(MgO)>30% made of calcined dolomite sand as main raw material. According to different production processes, it is divided into tar-bonded dolomite brick, light-burned oil-impregnated dolomite brick and fired oil-impregnated dolomite brick.
Dolomitic bricks are highly resistant to alkaline slag, but they are easily hydrated in the air and are not easy to store for a long time. They are suitable for AOD and VOD furnaces and ladle linings.
2 magnesium dolomite brick
The basic refractory material containing MgO and CaO as main components contains 50% to 80% of MgO and 40% to 10% of CaO. According to different production processes, it is divided into tar-mixed magnesium dolomite brick, light-burned oil-impregnated magnesium dolomite brick and fired oil-impregnated magnesium dolomite brick.
Magnesia dolomite brick has high MgO content, good slag corrosion resistance, hydration resistance and high temperature strength, and is suitable for AOD and VOD furnaces and ladle lining. The typical physical and chemical properties are shown in Table 5.
Typical physical and chemical properties of magnesium dolomite brick
3 magnesium calcium carbon brick
Magnesia-calcium carbon brick is a non-burning carbon-containing alkaline refractory product made of dolomite sand, calcium oxide sand, magnesia sand and flaky graphite.
Magnesia-calcium carbon bricks have excellent properties of magnesia-carbon bricks and dolomite bricks, have good resistance to slag erosion and permeability, and are suitable for AOD and VOD furnaces and ladle linings.
4 magnesium calcium brick
The main components of magnesia-calcium bricks are magnesia and calcium oxide. When the magnesia content in the brick is higher than 60%, the corrosion resistance of dolomitic refractories can be significantly improved, and the increase of calcium oxide content is beneficial to improve. The material is resistant to penetration and thermal shock.
3. Magnesia carbon brick
Magnesia carbon brick is a non-burning carbon-containing alkaline refractory material made of fused magnesia, high-purity magnesia and flaky graphite, and a phenolic resin as a binder. The production process is basically the same as that of general refractory bricks, but not It needs to be fired and only needs to be heat treated at 200~250 °C.
Magnesia carbon bricks are divided into four categories according to the carbon content:
1C 10%, MgO76%-80%;
2C 14%, MgO 74%-76%;
3C 18%, MgO 70%-72%;
4C 5%, MgO 82%~85%.
Physical and chemical indicators of MgO-C magnesium-calcium carbon brick
4.Al2O3-MgO-C refractory
1 aluminum magnesium carbon brick
The special grade clinker clinker is used as the aggregate, and fused magnesia or sintered magnesia powder and flaky graphite are added, and the phenolic resin is used as a binder, and after being press-formed, it is obtained by heat treatment at 200 to 250 °C. The aluminum-magnesium carbon brick has good resistance to slag penetration, strong corrosion resistance, good thermal shock resistance and low price, and is suitable for non-slag line parts of various refined ladle.
The national standards for aluminum-magnesium carbon bricks are shown in Table 5.10.
Physical and chemical index of resin combined with aluminum-magnesium carbon brick
2 aluminum-magnesium spinel carbon brick
Same as aluminum-magnesium carbon bricks, except that the pre-synthesized aluminum-magnesium spinel clinker is used as a raw material to replace or replace part of alumina and magnesia. Thereby, the formation of spinel during use and the resulting expansion effect can be adjusted and controlled, which is beneficial to improving the corrosion resistance and high temperature volume stability of the product, and is used for refining the non-slag line portion of the ladle.
3 magnesium aluminum carbon brick
The difference from the aluminum-magnesium carbon brick is that the content of Al2O3 and MgO is reversely changed, and the brick making process is the same. Magnesium-aluminum carbon brick has good slag resistance and strong corrosion resistance. The performance of magnesium-aluminum carbon brick is between magnesia carbon brick and aluminum-magnesium carbon brick, which can be used for the transition zone between ladle slag line and wall. Can be used on the wall of steel ladle.
5. Magnesia brick
1 burned magnesia brick
The calcined magnesia brick is a product which is fired at a high temperature of about 1500 ° C after being formed by calcination of magnesia as a main raw material. The product has good high temperature performance and strong resistance to metallurgical slag. It is widely used in steelmaking lining, iron alloy furnace, mixed iron furnace and converter permanent lining in steel industry; copper, lead and tin lining in colored industrial furnace.
2 combined with magnesium brick
The combined magnesium brick is a kind of product which is made of fused magnesia as the main raw material and is formed by high pressure molding and firing at 1800 °C. The product is commonly used in steel slag erosion and severely worn steelmaking furnace tapholes, slag line parts of non-ferrous metallurgical slag and the like.
Please send us your requirement by email.
ADDRESS:Fenlukou Town Yu'an District Lu'an City Anhui China-237143
Copyright © Greenergy Refractory and Insulation Material Co.,Ltd All Rights Reserved.


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Find the best places near you to buy premium quality CBD in Winterville, NC
There are essentially hundreds of CBD sellers in Winterville North Carolina however only a few sell CBD products with any kind of clinical efficacy. There are some very essential concerns to ask before determining where to buy
What is CBD?
Hemp oil is more extensively known to be in the Marijuana plant family. However, hemp does not supply the customer with high quantities of THC (like its relative equivalent does). Rather, it shares its mass amounts of cannabidiol, or CBD, with the customer.
For first time customers of CBD oil, it can be a little bit of an obstacle, as there are lots of things to take into consideration as CBD oil can can be found in several kinds. There is also a substantial number of different items as well as brands on the marketplace.
Where to Buy CBD Oil Near Me in Winterville
In order to get the CBD oil that ideal suits your requirements, the two crucial things to consider are the stamina and also concentration. Other elements to take into consideration include pureness and also the volume of CBD oil within the product itself.
The very first thing you need to find out about choosing a CBD Oil product is that they can be made from removes from either Hemp Plants or Cannabis Plants. And also, currently, those from marijuana plants are not legal in many states, nor can they be shipped throughout the majority of state lines.
if you wish to buy cannabidiol (CBD) oil items, you have to dig deep to find precise as well as up-to-date details. That's because, while CBD is increasing in popularity, reliable information is commonly scattered across the web.
What's even more, CBD is among the most misinterpreted nutritional materials readily available today. Lots of people confuse it with THC, the major psychedelic active ingredient in cannabis.
Contrary to these typical misconceptions, CBD is both legal as well as completely secure. It includes no psychoactive components, so there's no chance of "getting high."
Also if you're absolutely clear on the distinction in between CBD as well as THC, there are still several various other factors to think about before acquiring, consisting of brand names, focus, types of items, and also most importantly, your very own requirements.
One common misconception some people have about hemp oil is to believe this is cannabis. Despite the fact that hemp is part of the marijuana family members of varieties, it is very different from marijuana in lots of methods.
CBD Oil available consists of 0.3% THC (the legal limit for this item) and occasionally much less. Because of the low uniformity of THC, CBD products are not psychotropic and also does not trigger any impacts in the customer at all.
Hemp likewise includes fatty acids which have been understood to be great for the body. Unlike its marijuana counterpart, hemp has high quantities of CBD and also low volumes of THC for which its grown. While cannabis is illegal to consume in numerous states, hemp is slowly becoming more popular and much more states are legislating the uses of hemp oil for its citizens.
Find Pure CBD Oil Near Your Area In Winterville North Carolina
CBD derived hemp oil is a natural substance grown for many objectives, among which are the wellness benefits connected to this plant. Produce your very own chances and also discover on your own exactly how CBD obtained products can benefit your day-to-day life.
Previous CBD Shop | Next CBD Shop
When searching for the most effective CBD product, you'll see 2 types primarily around, available in the marketplace; complete range CBD as well as CBD isolate. The distinctions in between the two are rather noticeable. However the approach of intake, measurable dosage, and also time intervals can play a vital function in the effectiveness of CBD. As full-spectrum CBD is a lot more prominent, isolate has specific benefits that may not be negated.
What do individuals mean by Isolated CBD?
CBD isolate clarifies its name quite possibly. It refers to pure CBD that has actually been separated from all other substances in the cannabis plant, having absolutely nothing else. A 2014 study additionally demonstrated that CBD isolate can be helpful as there is no possibility of THC inadvertently making its means into the product. The people that live in states where THC is purely banned, it might additionally profit them. Isolate is additionally beneficial for sensitive to other cannabinoids such as THC. Isolate products are generally considered as having 99+% pure CBD.
What is indicated by Complete Spectrum CBD?
Complete range CBD refers to CBD products consisting of CBD in addition to all other energetic cannabinoids in the plant such as THC, CBG, CBN, terpenes as well as all the other nutrients found in Marijuana plant. Normally these remain in naturally happening proportions in the removed kind, from the particular pressure of the plant. They are likewise included intentionally into products to elevate the potency. Full Spectrum ought to be taken with some safety measures by those who get their medicines examined. The THC found less than 0.3% in full range hemp products can make drug tests positive.
Are you aiming to get CBD-rich oil? Discovering the right CBD oil can be an overwhelming job, especially if you are a novice. There are lots of means of acquiring your Cannabinoid (CBD) oil. You can buy the item online, from traditional store, co-ops, dispensaries, and also natural herbalists. CBD oil products can be made from essences of either hemp plants or Cannabis Plants. Depending on your preferred setting of consumption, the hemp-extracted oil is readily available in a series of applications including casts, topicals, vaporizers, vape pens, transdermal spots and as instilled edibles.
CBD oil is legal in 30 states where medicinal and/or recreational marijuana is legal, according to Governing magazine.
Seventeen added states have CBD-specific regulations on the books, according to Avoidance magazine. Those are Alabama, Georgia, Indiana, Iowa, Kentucky, Mississippi, Missouri, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin and Wyoming.
- Where to buy CBD Oil in Winterville NC
- Where to buy CBD Gummies in Winterville NC
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- Where to buy CBD Vape Oil in Winterville NC
CBD Shop Locations Near You
Winterville, NC 28590
Pitt, North Carolina (NC)


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Employment Tips
Interview Tips & Advice
Managers, professionals and executives are usually articulate individuals with excellent career and track records. They often do poorly in interviews because of a lack of serious preparation, and the belief that their accomplishments will speak for themselves.
There can easily be hundreds of job applicants competing with you for the same position. Never think you are the only job candidate and never underestimate those who are competing with you. Unfortunately accomplishments don't speak for themselves and a well-prepared candidate with highly-developed interview skills often gets a position over a better qualified candidate that was poorly prepared.
For mid level and higher positions the interview is not only used for gathering information about a candidate's experience and qualifications, it is a method of assessing management and presentation skills. Every aspect of the entire interview process is evaluated. Companies are not only interested in the candidate's qualifications but how well the individual will fit into the organization.
The biggest mistake in interviewing is not being fully prepared. Job Seekers must use every conceivable means possible to prepare for the interview and to allow ample time to fully prepare. Understand that interviewing is a skill and as with all skills, preparation and practice enhance the quality of that skill. Preparation can make the difference between getting an offer and getting rejected.
There is no one best way to prepare for an interview. Rather, there are specific and important strategies to enhance one's chances for interview success. Research sample interview questions and answers, learn about the various types of interview techniques. Research the company, industry trends and prepare a list of questions to ask the interviewer. If you don't know what to expect it is unlikely that you will be able to successfully convey your qualifications and interest in the position. Studies show that most interviewers are looking for reasons not to hire a candidate so you must overcome this resistance.
Tips for Your Job Search
Most managers, professionals and executives do not have much experience interviewing from the candidate's side of the desk and should investigate the expert advice in the Interview Directory. Interviewing is a skill that requires preparation and you must anticipate and be prepared to answer all the possible questions you may be asked.
George Smith


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I have a wedding videography company and i will be needing extra editors to fulfl this upcoming season
We are a restaurant and event space. Looking to dev... restaurant dining traffic, live music event attendance, and booking weddings and private events. Develop and execute a social media campaign to generate leads for our wedding venue, analyze and develop strategy for other goals using Facebook, Instagram, Google and other platforms as necessary.
...programmer. Firebase Storage could be a good option, unless a better way is suggested by the programmer. * App will be posted to Play Store, HOWEVER it will be a private (invitation only) app, that requires an Activation Code provided by Management, by email and other ways to their sales team. Thus, when the app is installed and used for first time
BIRTHDAY INVITATION FLYER Valencia's 31st Birthday Dinner Colors: Red/White/Black/Silver Date: 3.30.19 Location: Acqua 2192 Niagara St. Buffalo, NY 14207 Music By: DJ Spin Time: 6pm - 10pm Tickets: $45 (Includes Dinner and Dessert) Attire: Fashionable/Trendy *All guests need to RSVP by 3.23.19 at 716-603-3818
For FRENCH speaking freelancers ONLY. J'ai un livre en format Words de 21800 mots à faire corriger. J'ai 10 Chapitre il s'agit d'un sur l'immobilier de mon histoire et de plusieur truc que je donne. J'aimerais ensuite faire une mise en page pour l'impression d'un livre papier. Je pourrais vous donner les spécifications dés...
glossy tales team doing a wedding photography and videography related all work. Also doing Film,Fashion, Corporate photography and cinematography work.
An app that encourages initially anonymous, but consensual dating. Users within a particular social area or gathering enable their bluetooth devices after signing up fo...by another user. Users initiate that they are available to be contacted, and give hints of who they are based on their icon. The other user either accepts or rejects the invitation.
German Freelancers ONLY I am into digital marketing.I am looking for somebody to write contents in Germany.
Looking for Recruiters who have experience in hiring for Data Analytics projects.
This is Edward From GD Tech Street, we do provide hosting solution for website designer / developer at partner price. Your earn range can be 30 - 50% margin from our selling price, and the price is cheaper then reseller hosting. For Example, USD 66.00 for one year package inclusive domain. you will have USD 16 for commission.
Prepare 15 folder structures layou...Business Marketing department 6. Business HR department 7. Business finance department 8. Business inventory 9. Business research and design 10. Personal high school 11. Personal wedding planning 12. Business event planning 13. Personal holiday planning 14. Personal property portfolio 15. Business sales department
We are looking to find someone who can design our wedding invitation pack to Include: Wedding Invitations, Rsvp, Menus, Reception Invites, Information Sheet. To be Printed and deliver to the UK Looking for around 100 complete sets. Something on the lines of the attached photo
Wedding Snapchat Geo Filter with custom image and the following details: #DosunmuRoyalWedding 23.02.2019 Can I have a gold outline around them the couple as well
My wedding is 05/23/2020! I am looking for someone to be the videographer at my wedding. I would love for you to have a drone and modern style of the 'highlight videos'.
Omatra hotels is looking for freelancers who can help with sales on commission basis only. Please feel free to contact me *Removed by Admin*for further details
We have an app where you need to record sentences. It has total 220 sentences, it may take 40 minutes to complete I will share username and password to freelancers. Check the videos attached. Yo u have to send me screenshot after completing 220 sentences
...willing to attend the wedding and reception, enjoy the ceremony and host the Facebook Live on a Closed Group I have created. The wedding will be held on March 16th at 2 o'clock. I would need someone there from approximately 1:30-6:30? That will be determined on the day of the wedding. I will work with you on the day of the wedding, making sure everything
Good afternoon, I have wedding photos, I need to tint and retouch to do. Can we? About this style
I need an iPhone app. I already have a design for it, I just need it to be built.
Hi, I have two photos I want put together to make one photo, with the finished product high resolution, with a transpare...make one photo, with the finished product high resolution, with a transparent background. What would the cost and time be? I've attached the two photos - The blue circle of wedding items to be inserted into the circle of homes.
...the existing site we have which is based on Wowonder social community platform and has it's own API. Here are some of the additional specs: - Open and private rooms (by invitation only) - host can limit the number of room participants - 3 different room views: Grid view (all streams the same size), Hero view - selected stream is 60-70% + small grid
New website development and mobile app development
i need original floral patterns in just like it is in these wedding invitations .
The contest winner will get a long term partnership. [đăng nhập để xem URL] download the files from link above. music you can use: [đăng nhập để xem URL] or any other music which is is good looking for this video.
Looking for someone who is able to edit a wedding full length video roughly 60-120minutes in length. Need to be color corrected, with titles, and sound design
need a logo for the Ross/Lisonbee wedding for use in website, printed materials, engravings, etc. logo must include reference to Grand Teton mountains, and ideally some reference to bees or honey, and trees or bark (aspen bark). wedding takes place 08/25/2019 in Alta, WY, overlooking the Grand Teton mountains. Wedding colors are coral with a dark teal
Hi all, I am looking for voice over freelancers to do some audio recording for American language. Please message me if the above language is your mother tongue language and send me a voice sample of few words. Thanks
...authentication. To start, we need to verifify the ID of the voters with the mobile name and email address. Develop a procedure that leads to a obtain a verified ID before sending the invitation to vote. After the voting each voter receives the votingresult. But we we are not so far yet, first things first to find someone who has experience with verification procedures
...well," A "I think I will concentrate, but quite it" A "What shall we do if tomorrow is a byte ended?" B "I am planning to meet my friend ^ ^" A "Ok?" A "Because I have an invitation ticket for a movie, I thought something was wrong with me" B "I do not like movies so much" A "Really?" A "I thought I should se...
I just started a wedding and event planning company. I bought a wordpress plan for a website and I'm having trouble building it the way I want it. I also have access to Adobe Dreamweaver. I have all the tools to build it myself, but I need assistance getting it done.
A invitation video for an event. I have a 25s animation video already that needs a few tweaks.
We are after submissions for a wedding logo that has the initial D and A. Brief as below: 1. PNG file 2. Monotone black and white only 3. Botanical theme - cotton flowers, banksia, eucalyptus 4. Contemporary, clean lines and font 5. Luxurious and elegant


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You start your day with a check-in on social media. You spot a negative review on your Facebook page. Do you:
- Ignore it and hope nobody sees it?
- Respond?
You start your day with a check-in on social media. You spot a negative review on your Facebook page. Do you:
Inbound marketing. Conversational marketing. The subscription economy. Growth hacking. Each term, now ubiquitous, had humble origins but a profound—and profitable—impact.
I don't have to convince you that email is important:
But do you work on your email? Is email an actively managed and QA'd operation in your business?Keep reading »
Most hurricanes that reach the United States
So what does an afternoon rainshower over Cape Verde tell you about the next Category 5 hurricane? Often, little more than a form fill tells you about the potential for a five-figure sale months down the road.
Website redesigns are a huge risk. You can throw away years of incremental gains in UX and site performance—unless you have a battle-tested process.
With a single click, a user can destroy Google Analytics data: Moving from an AMP page to the main site or the main site to a payment processor can turn one visit into multiple sessions, mucking up source data along the way. Keep reading »
As a SaaS company, both your product and service are unique solutions, and your pricing page should reflect that. Keep reading »
As we wrap up 2018, we went back through everything we've published this year to find the 10 most-read articles. Keep reading »
For many, Google Analytics 360 is a black box. Marketing and sales collateral from Google is spartan, and common refrains about key features—like unsampled data—seem unworthy of a six-figure bill for most sites. Keep reading »
To assess the State of the Conversion Optimization Industry in 2018, we gave a 26 question survey to 701 people who work in the optimization space.


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Search for bedbugs yourself, or hire a professional to do an inspection. Some inspectors use specially trained dogs to hunt down bedbugs by scent. Bedbugs' small, narrow bodies enable them to squeeze into tiny spots—like the seams of a mattress or couch, and the folds of curtains.
Seal up any open areas. Glue down loose wallpaper. Caulk cracks in furniture and around baseboards. Tape up open electrical outlets. Finally, move your bed at least 6 inches away from the wall so bedbugs can't climb on.
Bedbug bites usually go away after a week or two. You should contact your doctor if: the bites don't go away after a few weeks, you develop a secondary infection from scratching the bites, you experience signs of an allergic reaction, such as hives, You can use a topical steroid to treat bedbug bites on the skin.
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