Certification of Compliance with the Open Meeting Law. The agenda was posted on the 15th of December at 2 p.m. Thank you. Please join me in the pledge of allegiance. And to the Republic for which it stands, one Nation under God, indivisible, with liberty and justice for all. Thank you. Roll call. There are 22 supervisors present. Thank you. Approval of the November 7, 2017 journal. Supervisor Winkle. Move to approve. Thank you, Supervisor Winkle. Supervisor Koch. Second. Thank you, Supervisor Koch. Any questions or discussion? All those in favor, vote aye. Opposed, nay. Motion is pretty unanimously. Okay, consideration of appointments by the chairperson. For the Monarch Library System, a reappointment will be brought into the Veterans Service Commissionary Appointment, Jennifer Samson. Supervisor Epping. Thank you, Chairman. Motion to approve. What are the sub-appointments? Thank you, Supervisor Epping. Supervisor Tastrui. Thank you, Mr. Chairman, all second motion. Thank you, Supervisor Tastrui. Any discussion? If not, please push your i-button or an a.  Thank you. Presentations. We have none. Public addresses. There was one with the Roger Hollingstead, but he called and could make it to him. Thank you. Letters, communications, and announcements. We have none. Thank you. County Administrators Report. Adam? Hey, Mr. Chairman. Good evening. Good evening. Well, we should be out of here relatively soon, I think. I hope too many of you weren't disappointed when we said Administrators Report and John didn't respond. There is none. I have four topics I want to touch on briefly. One, as you are aware, if you review the e-mail that I sent out, I think yesterday in response to our friend, Supervisor Jim Baumgart, Chairman Weger and I did have an opportunity to testify in support of Senate Bill 466 and Assembly Bill 588. And as you know, this has been a topic of discussion in our community for years. The EPA has regulations in place that are very important to protect air quality for our constituents, our family and friends, and what the EPA does and the Department of Natural Resources does is very important. However, we have a monitoring station right on the shore of Lake Michigan that is capturing predominantly emissions or pollution from other areas outside of Sheboyton County. From Indiana, Chicago, Illinois. So, the Chamber and our local businesses have been working for some time in Sheboyton County, other local units of government, as well as the Department of Natural Resources to see what can be done to address the problem that the EPA is utilizing this monitoring station to put regulations here in place that our citizens and businesses are subject to that is really punitive and unfair because they're relying on air quality data, again, measuring pollution and emissions from other areas outside of Sheboyton County. So, to the credit of the County Board, working in collaboration with the DNR and the Chamber, we established a second monitoring station in Haven, which is on County property via one of our highway sheds in 2014 to start capturing data from the emissions of our actual local businesses. What we're producing here. And now after three years of data, it's been determined that we are meeting EPA regulations, at least to the extent where we wouldn't need this more burdensome or heavy regulation that, again, is not only punitive to the citizens and local businesses here, but really can have an impact for a business choosing to expand or families to move here to work in this community. So, Senator Devin Lemieux as well as our other local area legislators proposed legislation for the DNR to say rather than collecting the data from this station, we should be collecting it from the Haven station and sharing that with the EPA, the EPA should be relying on that. And ultimately this may be more about music than actual action because the EPA needs to listen and to date they have not and it will be the EPA's decision on which monitoring station they ultimately choose to continue to use. So, Chairman Wagner and I, Mayor Van Der Stien and other community leaders weighed in and expressed their support for this. There is an accompanying bill that I think Senator Strobel has authored and I'm pretty certain that's the bill that Jim Baumgart was alluding to where Senator Strobel was looking for the DNR to really roll back all sorts of regulation that's been put in place for a citizen's best interest by the State Department of Natural Resources and it was looking for one swipe to eliminate a lot of this regulation and any regulation the DNR would put in after 10 years would just automatically expire. Imagine a situation where rules you put in place or other good governance that's in place whether it's speeding limits what have you or just gone revisit and start from scratch without anything in play. Obviously that can be problematic. So, I don't know if that legislation is going to have legs or not. Personally, Chairman Wagner and I do not support that legislation I think and would rather rely on our state and our State Department of Natural Resources to put in protections for our citizens and the federal government but that's a different piece of legislation. And, of course, for our TVA viewers and Edmund Fellner's here from the Plymouth Review, I think it's important to continue to make sure that the community is aware that this is an unfair, punitive regulation that the EPA hangs their hat on because of pollution from other states and as the DNR has concluded even if all of our local businesses completely eliminated any emissions, it would not impact the Kohler Andre monitoring station enough to reduce the current level of regulation that the EPA is requiring. So, it really boils down to good science and common sense to make a change there. Second thing I wanted to touch on was again something that Chairman Wagner and I recently had the privilege of participating in and it wouldn't have happened if it wasn't for the county board. In 2016, as you know, under the leadership of Ed Stangle and many others predominantly at our Health and Human Services Department, the county established the Drug and Alcohol Treatment Court. And this is an initiative that we need to do more of rather than people sitting in our detention center not getting the help they need to get back on the right path, get back with their families, be contributing members of the community rather than sitting in the detention center and just not getting help. Individuals that meet certain criteria are getting all sorts of support from our judicial branch, our Health and Human Services Department, law enforcement, it's an incredible collaborative effort to help people. People who have made mistakes would certainly deserve a second chance. And so Ed Stangle reached out to Chairman Wagner and I and Tom had a chance to say a few words to the group but they had their first graduation. That was last Friday. It was Friday. Last week Friday. The older I get, the more I lose track of time. Last week Friday and I can't tell you how heartwarming it was to sit there and see the first graduate after a year going through this process. I mean, there's a lot of involvement and responsibility that those individuals need to take to be successful. To see that play out where this person with their child and I don't know if it was a wife or significant other in the courtroom going to be able to be reconvened with their family and then the individual spoke to the judge and everyone involved and thanked everyone in the county including the county board for the support to get this program going. So if you ever get a chance to sit in on one of these court proceedings and see how they interact with the clients and get a feel for the different resources that are pulled together I encourage you to do it because it really I think reflects so well on Cheboy and the county for providing us and if you see Ed Stangle which certainly you see Judge Stangle at our legislative breakfasts and occasionally other forums please thank him because he does an excellent job. The third thing I wanted to touch on as I have every board meeting for quite some time now is the transportation complex update so of course the ones you can power that up for me we're about 75% done we continue to make good progress the staff from Elkhart Lake and Plymouth Sheds are praised to move in either year end which obviously is within the next couple of weeks or as Greg Chanel shared with me today it might be the first or second week in January because they obviously are working hard to make that happen but the final facility will be completed in April excellent. So what's happened we were so blessed with some good weather up through December 1st I think deer hunting weekend was miserable but the week thereafter really we had some nice weather and our excellent Highway Department crew not only did over 31 miles of paving this year which they take a lot of pride in but they got all the paving done around the transportation complex and obviously that's nice for maintaining it the winter and plowing people coming and going so they were able to get that all done by December 1st next slide here's an aerial this was taken before obviously they completed all of it but you can see the paving in the back is quite a bit that surrounds our footprint there and again our workforce did it and they did an excellent job and we're just so thankful just long enough for them to be able to get in there and do so. Just to get you orientated that's the salt shed that's right in the foreground there the building right in front of that is the cold storage facility and then of course the large building in the background is the main head another shot of it there you can see the fuel area right to the in front of the building again it's all now a beautiful asphalt and looking good next slide. The cold storage if you drive by now you see them starting to work on that and getting the walls going up so that's in play next slide this is a beautiful training area for our staff as well as it's going to serve as an emergency operations center and not a lot of people may recall that or have thought about that you think about this transportation complex and the importance of it and the investment it is for our community but there was enough more sites that went into this building and the plans and the location that Steve Steinhardt our emergency management director and others have worked together to make sure that this room has all the capability that in the situation where we have a real emergency or we lose one of our main facilities this is a place that emergency responders leaders can convene when there's a real crisis so that's going to be a dual opportunity there for use of the facility next slide this is the main parking area and the picture really doesn't do it justice because for those of you who have been in it and the number of you have it is immense it is a large room but what's different today the last time you were in there it is now painted next slide over 20,000 gallons of paint are going into this complex so a lot of people have been working hard on getting the paint on the next slide and to help them out we convened our department heads and you can see those buckets in front of us there and we all pulled together we had a department heads meeting out there a week or so and toured the facility along with the former chairman Roger Distrudi and Mark Winkles there and I know the chairman Wenger went through it the week earlier when we had a meeting out there most of our department heads had a chance to come out and see it many of them for the first time and as you can see we looked really good in those outfits next slide this is the locker room the staff of our facility are going to have a very nice locker room next slide this is the salt shed just ordered all the salt I guess that holds what salt in this facility alone Bites thank you Bites, 5,000 tons thank you 5,000 tons of salt in that facility alone what did he share with me that we ordered 12 tons 5,000 tons going to the new complex site and selling for about $72 which is depending on your perspective maybe not too bad we've paid more but we've also paid less hopefully we're not going to have to be using too much of that too soon sounds like we've got weather coming Thursday 75% complete Elkhart and Plymouth staff are going to be looking to move in within the next few weeks and we'll have it done in April and so far so good wanted to end on the budget and I shared this snapshot before but it really is a credit to beast and just some good fortune as you recall we budgeted $24.8 million plus $25 million for this facility the bid process produced a million dollars under budget thanks to some competitive bidding so that was good we have a significant contingency because of course you always have change orders or things come up and because of the good attention to the budget and how the building has been going up the finance committee the transportation committee agreed that we could reduce that contingency by $500,000 so the bonding resolution you have before you and there was a memo from our finance director in your packet we'll be looking for not obviously a motion to support that which has already been this bonding has already been supported as part of our budget process and the five-year capital planning process will be reduced by half million again because we're in good financial position with completing this transportation problem so I feel good about that thank you Chris finally if German Weger and Vice-German Martensi could join me we have two service award pins tonight that's why there's so many people here this evening family and friends like Aaron Brault Dave Lafine if Aaron could please come forward with a highly coveted service award discussion good evening your wife and kids couldn't make it tonight apparently you didn't invite your parents you know they watch it on TV well we'll muddle along the best we can I'm very fond of Aaron as I am all of our department is but Aaron started with us ten years ago and it's hard to believe that ten years have passed when he started he was hired as transportation program coordinator relatively young new position in our planning and conservation department as you know we were so fortunate to receive this twenty five million dollar grant as the three other communities across the nation and Aaron had a key role in implementing that and working with the community to come up with plans and projects and see it through and shortly after working in that position manager of that program and shortly after that we had an opening for director and I asked him if he would serve as our interim planning and conservation he agreed and he shone and in 2011 Aaron was appointed our director of planning and conservation and what I find incredibly remarkable about Aaron is young hadn't been a planning and conservation director before hadn't worked for a county bar size with roles and responsibilities that he and his staff have and his track record as a planning and conservation director I have to believe his track record is as good if not better than any of his peers in this state if not the region it is remarkable what Aaron has accomplished obviously with the support of the precom committee as a whole but it is remarkable just to name a few non motorized transportation grant as I mentioned he took the lead in implementing that not only as a staffer but ultimately as a director and total it is a $28 million grant to Sheboygan county actually received a little bit more than originally projected the Sheboygan river and Harvard dredging project Superfund site one of the dirtiest and dirtiest in the country black eye of the community Aaron stepped right in helped lead the charge to get people to come together from all walks of life ultimately this community was able to capture over $100 million of resources to clean up the Sheboygan river and Harvard and dredge that filthy Aaron's leadership was just outstanding outstanding in addition to that he and his staff have been applying for Brownfield grants to help with redevelopment areas and they now have not only been more successful in that area than ever before but it's led to about $25 million of redevelopment thanks to Aaron's leadership thanks to his staff and then finally and I sent an email just this afternoon about our Amsterdam dunes wetland mitigation bank and preservation area and our really two tremendous opportunities to preserve a beautiful area and secondly to create this mitigation bank that is in the works again under Aaron's leadership so ultimately we can help with growth and development in the community. Natural resource damage assessment grant is looking favorable as they touched on but Aaron also was able to successfully apply for what may be the largest state stewardship grant in history of the state $2.4 million toward our preservation area I doubt there are too many planning and conservation directors that can share that kind of track record this is just four examples so Aaron I'm so proud that you work for Shenboyle County I thank you for your 10 years of leadership I thank you for the team that you put together the beautiful family that you're raising you might get to see is son and daughter from time to time I see him at the YMCA Aaron and his wife Jenny they're just good people and he's making good things happen so please join Chairman Wagner and Vice Chairman Martensi and I in thanking Aaron and recognizing him for 10 consecutive years of service to the people in Shenboyle County 30 years of service 30 years of service Dave and I didn't spend as much time together during our 10 year here I've been here going on like 19 years and we haven't spent as much time together as Aaron and I have and part of that he's the corner you know but I tell you every time we sit down and talk and it always happens during the budget development process but occasionally in other instances he is one of the most sincere down to earth genuine people you will ever meet and the work that he does it's fascinating what he does I think largely we take it for granted we take it for granted because one is very good at what he does two has been doing it for 30 years but it's just one of those areas that someone takes care of that type of important work 1987 he was the elected corner and of course his mission is to help families and loved ones whether it's a death investigation whether it's signing a cremation permit whether sadly it's an autopsy he is working with people at a very difficult time it's challenging work and much of the work he does follows state statute he has to do and needs to do it and I can't imagine many of us would want to do that kind of work takes a special person he has four part-time deputies of course Dave has built his team and he's starting to think about how much longer he may want to do this type of work but in 2015 in great part because of Dave's own advocacy the county board changed his position from an elected corner position to an appointed medical director medical examiner and Dave really advocated for it and that was interesting because when you're talking about a change like that that can create some angst or is that really the right thing to do well he's got a strong medical background the work he does requires a medical background he wanted to retire that we could hire the most qualified person with a medical background to continue the important work that he and his staff do so he personally helped lead that charge with the law committee and with myself and the county board ultimately the board made the change and we were fortunate that he stayed and who among us noticed any difference whatsoever totally a smooth transition handled it beautifully and now when Dave does decide to retire and we're in no hurry but when he does we're going to be in position to recruit and hire the most qualified person we can in a position so I know Dave has told myself and others that he takes a lot of pride in helping with that change I certainly appreciate his leadership and his support with that and I encourage you if you haven't taken the time to talk to our former coroner and current medical examiner to do so sometime I mean that necessarily be someone who we're hoping shows up at our front door but he is a very very good man who does incredible work thank you 30 years next I'd ask if we have consideration of committee reports at Dave's committee resolution number 19 regarding authorizing the issuance and sale of 7.18 million of general obligation promissory notes right and I'm going to ask Brad Bigote from our bound council from Baird to come up first and explain it before we get on it Brad Bigote with Baird we're serving as underwriter for the issuance of this obligation I'll walk through a presentation packet prior to this meeting and it was taken up at an earlier meeting on the executive committee this evening the finance committee the first page after the cover provides a summary of the resolution we're considering this evening by way of description this is a general obligation promissory note issue size of 6.680,000 that represents the $500,000 reduction in the bonding for this project that was authorized by the county board the funds will close and be available to the county on January 10th of next year and they're scheduled principal payments annually beginning May 1st of 2019 with the final payment of May 1st of 2027 first interest is budgeted for payment on May 1st of next year and then interest payments will be semi-annually through 2027 there is a call feature that is the county has the ability to prepay this debt through financing or with funds available on hand so the 2026 and 27 maturities can be prepaid at the county's option on May 1st 2025 for any business day thereafter I've outlined two ratings that are assigned first there's an issuer rating for Moody's investor service Moody's did was not asked to assign a rating to this specific transaction but rather Moody's release the report that it provides for these types of ratings it's an annual rating report and Moody's assigned the double A2 rating for the county's debt the complete rating report is attached from both of these just a few of the highlights I want to be sure to touch on on both reports first Moody starts under the credit overview section by describing Cheboygan very good and they continue on in that paragraph to talk about a substantial tax base and healthy socioeconomic profile all of the other factors cited on the Moody's report are also positive by way of finances they're calling the financial position of the county very strong debt and pensions are identified as extremely small the economy and the tax base very strong overall and then the management and governance section follows the second rating you'll see is from S&P Global at Standard & Poor's Global Standard & Poor's was asked to assign a rating to this transaction Standard & Poor's assigned a double A- rating and this is the first time that Standard & Poor's has rated the county's debt their rating report is also attached there's a very significant difference with their characterization of the economic condition of the county where they're calling the economy of the county weak I couldn't disagree more Standard & Poor's is missing the mark in their characterization of the county's economic profile it's really a flaw in their analysis and that is that they look at the industry concentration and if that concentration is above 30% in any industry that puts an anchor on the county's rating while the manufacturing concentration here in the county is just over 30% Standard & Poor's methodology is very rigid and is not compromising so for example they're not taking into consideration all of the food related manufacturing, medical equipment and so on things that are recession troops so to speak and that's leading to this 30% concentration which is leading to this mischaracterization of the county's economic condition all of the other factors are very positive and all of these other factors that Standard & Poor's evaluates are factors that you as elected officials and your county staff have direct control over influencing so specifically Standard & Poor's talks about strong management good financial policies your adequate budgetary performance that's a recognition that you maintain a balanced budget very strong budgetary flexibility they talk about the solid fund balance of the county very strong liquidity strong debt and contingent liability position and a strong institutional framework so but for their misunderstanding mischaracterization of the economy very very positive overall we bear this out in the marketplace this morning taking orders from investors the initial interest rate that we had anticipated the initial rates we went out with to the market were at 2.42% for this obligation we had such strong demand there were so many investors that wanted to buy a county's debt and invest in the county we were able to reduce that interest rate and that reduced rate is reflected in your resolution it's here in terms of summary that rate is 2.39% so you're getting a financing package that's going to be paid off by 2027 below 2.4% we remain in a very attractive interest rate environment and when the county is taking on a project like this transportation complex and your other capital projects that this is financing it's really a very good time to be in the market and to lock in rates at a very attractive level on the following page there's a very detailed financing plan I won't walk through this line by line but I would point out that this plan was taken to finance it was massaged it was designed to meet the goals that the county needs to meet in allowing for potential future debt issuance it doesn't commit to any future debt issues but there's room to layer in borrowings if needed out into the future and there's overall a downward movement in the debt repayments so this plan as it's presented here meets all of the goals that were laid out by the finance committee prior to securing this debt the last sections here have detailed, the detailed rating reports that I've already referenced I won't walk through those again line by line I covered those, the high points on that I wanted to make sure that all of the county board received printed copies so that we have hard copies of those reports so with that I'd be glad to go into additional detail to answer your questions so glad to see you Rainer Rainer I do have a few questions because I know the tax bill is both in the House and the Senate will you tax this one of the and it to the finance refunding of municipal loans and will that amount the situation? it will not allow repayment in advance of the call date once at the call date the county can repay you with other bonds or with other available funds so in this case the call date would be quite a few years in the future correct? correct and so when we look at the county's overall debt profile that's why we make sure to have other debt issuances that have call features that are earlier to provide the flexibility the county may need so that legislation or that change in the tax law will not impact the previous bonds that we had on standing it prohibits the issuance of tax exempt debt to advance refund any other obligations so it doesn't change those call features it just prohibits the county from issuing debt in advance of those call dates on the tax exempt basis so we appreciate that change then since we typically do pay the county still has the ability to issue taxable obligations to prepaid debt in fact I just with another issuer entered into that type of an arrangement where taxable bonds were issued to advance refund tax exempt debt so you're not locked from the market you still have flexibility not as much flexibility though that we had before the end of this year do you see any other I've noticed there are a number of pieces relating to municipal bonds that aren't what they're saying because of the type of state mobile tax deductions in part will be reduced there's a greater increase in the high state areas is that something that's driving the demand on your specific issue it's driving the demand this is the name it's the good credit quality of the county it wasn't sure if it was related to some of the tax of prospective tax changes that were coming out driving the demand for this thank you surprise or epic thank you very much as you stated your true interest cost is 2.39% that was negotiated from what 2.9% the initial was 2.42 this morning subsequent to that order period I'm not much in the financial but 2.42 2.39% it doesn't seem like to be that much of a substantial change is it I suppose on a large volume like we're doing it's a substantial amount this type of market it has a very sharp edge so we can see interest rate movements of less than 100th of a percentage point in this case we're seeing a movement that's as a follow up question to that is the fact that that S&P's rating was not as good as Moody's did that have the impact that had on the better interest rating less than 2.39% yeah the standard pours rating coming in where it did and probably had an estimated impact of .05% or 5 basis points so a small impact to convert that to dollars it's around $1,500 annually throughout the repayment period of these notes I was just disappointed that S&P was under I think they would have gotten a better rating I completely agree S&P really missed the ball on the economic environment and you're a county with 2.5% on employment that's essentially full employment from an economic standpoint you've got a very solid tax base in manufacturing sure but broader than that throughout the county residential and commercial and you're a very well managed county so I completely agree that the standard pours did not get the rating right how do we deal with that? well the Moody's report came out one day after that standard and pours report the investors in your debt have access to both of those reports and they're reading both of those so they're disclosed out on dissemination websites and there's notifications that are coming to the investors of your debt and they're updating these reports and they can see how strong the Moody's disagrees with standard pours analysis okay thank you very much for that explanation thank you Supervisor Epping anything else for Brad? thank you very much Brad then I'll go back to Supervisor Weigman thank you Mr. Chairman I'll move for an option of resolution number 19 thank you Supervisor Weigman and Supervisor Winkle but in our point of order Supervisor Weigman, would your motion adopt as amended? yes thank you thank you this gets a little convoluted so now I need a motion to adopt as amended before I vote Supervisor Gehring thank you Mr. Chairman I would like that motion to adopt as amended to a new amount to the lower amount thank you Supervisor Gehring thank you Mr. Chairman okay now we're voting on to adopt as amended which was the reduction I'm being corrected here by Carl thank you Carl everybody square? the deal is this when the resolution first came on it was for the 7 million dollar borrow your budget was adopted knocking a half a million off as indicated because of the work on the transportation complex so when it was introduced it was the 7 million when it got to the Executive Committee it was knocked down by the half million so it has been introduced as amended out of the Executive Committee however when it came out of the Executive Committee it had certain blanks in it because as Brad indicated until it actually comes out for solicitation we can't fill in the blanks the blanks were filled in at the meeting of the Finance Committee just before the Board meeting tonight so therefore you need to vote on amending the Executive Committee's proposal which amended the original finance so you're voting first to amend the Finance Committee's report incorporating the numbers that Brad provided this afternoon and you wonder why I got confused thank you Carl, you're right I know you're right so everybody's square we're voting on this now so push your I button or an A button I got a motion no more motions upon the completion of the debate you don't need any more more discussion discussion discussion discussion discussion discussion just a quick question what is our total bond and indebtedness for the county after a while back we took out 10 million that's still on my desk so I'm just kind of curious and I'm sure we're well within the limits but I'm just wondering what we have out there I know at the leadership every year we talk about that we show that graph and we're substantially below the limit but I've got the number off in I know Wendy do you have that available let me push your button alright that was very innocent thank you Wendy we're projecting 36.8 okay thank you Supervisor Hoffman I won't use that phrase again Supervisor Ureter I appreciate getting the answers to some of the questions I got out yesterday and getting that information and you know I was thinking the same situation as Brian where back in June we incurred a general obligation note for 10 million dollars that was on actually May 16th of this year, 17 and now I understand this is for 2018 debt one of the questions I have is April May timeframe that 10 million dollars was noted as for the capital improvement for the new transportation complex you'll see at this point portion of this 6.7 million dollars is also for the transportation complex and the 6 were basically the transportation always directed towards me in the night okay thank you even if I don't have the answer I find the person who does so that was your question is first we borrowed back a transportation complex now this 10 million or 6.7 million dollars is also for the transportation complex why we did it over to Wendy you want to answer that please the 10 million is for it included the transportation complex but it was for all of the 2017 5 year capital plan capital projects and that is the same for the 6 million year it is for the 2018 all the capital projects in the 5 year plan for 2018 so a combination thank you oops go ahead so then I realize our self-imposed debt limit is 11 million dollars per year and if that 10 million was for I don't think that's right it's not 11 million dollars every two years self-imposed debt limit you voted to go above the self-imposed debt limit so there is no self-imposed debt limit for these borrowers you have resolutions in both the November cycle budget cycle in the year before approving going over the self-imposed limit okay thank you so for these last two years then we've gone over our self-imposed limit and we've given our self-improval to do so go ahead so I'm thinking through this standpoint that we also just instituted the sales tax part of that will be used for roads because the budget for roads is 6 million and we're anticipating 9 to 10 million dollars from the sales tax so I guess I'm kind of struggling with the need for extra and definitely was glad we're reducing it from the 10 to the 6.7 but I'm still trying to grasp my hands around with that added sales tax hey keep in mind on the sales tax the roads are then we used a million dollars for property tax reduction and we used a million and a half that we're sharing so that upset number 2.5 million dollars right there go ahead half percent sales tax as you know is a separate matter we're sharing a separate matter from the bonding the bonding before you today we're fortunate to be able to reduce it from a little over 7 million to 6.6 that's good and yes it is more than the self-imposed but that's because the board chose as part of the five-year capital plan and the budget adoption which has already happened already gone through and vetted this for months as well as discussed the annual county board leadership forum so this is really now just following through to complete our transportation complex as well as the other projects that the board moved and voted on as part of the five-year capital plan and the budget and both documents by the way are now have new columns on them and are on your desk but we adopted the budget and five-year capital plan in the full winter already so those decisions have already been made I think we're going to bond for it thank you Supervisor Eppett thank you Chairman Whitmer when Supervisor Greener starts talking about all these figures and bond limits and whether or not we're behind or above or whatever it is my understanding and just to keep it simple for my own understanding we initially had bond limits of $4 million over 2 years each of you each year over each year so because we have these projects that we wanted to and because the market was at such a state that we could get money at a very reasonable rate we increased our our spending limits ourselves as a county board right? and so at this point is my understanding and correct me if I'm wrong we are still within our own self-imposed bond limits but they're a little bit bigger so initially we just started all of it is that correct? I think you're right you just shed some light on the subject thank you I just let it thank you Adam you want to for clarification and again this is a successful track record as well over a decade ago the county board established a self-imposed bonding limitation we have followed that very very closely also bonding and why we got the kind of good rating reported from these well below the state imposed limitations that's for certain we have made an exception for the transportation complex that's why we're above and beyond as well as the other areas that are in the five-year capital plan but going forward you now have further reduced our self-imposed limitation finance committee recommended to reduce it from four million a year or eight million every two years to two and a half million a year so we have further reduced our own self-bonded limitation which we intend to follow going forward unless the board determines that there's a project immense enough such as the detention center which the law committee was successful hitting in the five-year capital plan perhaps five years out at the cost of 25 million that would be an opportunity where you probably have to go above and beyond yourself imposed but we continue to lower that bar which is again what the county board is a good successful financial tracker and a surprise to the finance chair thank you Mr. Chairman I do want to point out we have a 24 million dollar project here that came in under budget our plan was to borrow as little as possible and use some general funds when you look at what we did last year what we did this year we borrowed about 14 million for that project and the rest have been funded by the sale of properties and by coming under budget so the other monies were for our capital budget last year about two and a half million dollars now I would remind the board we don't always go for bonding every year we typically bond every other year so if we're asked if our capital projects budget is two and a half million a year we usually go up market then every two years about five million dollars and that's the intent going forward here hopefully we have no other big projects in the face for a while thank you Surveyser Weigman Surveyser Hoffman thank you Mr. Chairman I voted for this increase in the bonding limit and that's because I think the future is bright for Sheboygan County I believe in Sheboygan County and I think we're on the right track we put all our our trucks so on and so forth and one central location for maintenance and things like that yes we'll have a couple other sheds but I think this was the way to go I know it's expensive but I think the future is bright I really believe that so that's why I voted for this bonding increase thank you Surveyser Hoffman I think you're at the limit of three this is Surveyser Rainer this is your third one your relationship to the roads are not on the capital plan and we're anticipating getting after we reduce the other pieces we have at least 7 million dollars so we have an extra million dollars that are not being used for roads is that anticipated to just go on our general fund that's really not on this bond issue that's another I guess I'm looking at it is that a million dollars then that would be used for other capital projects I'll just say quickly with the sales tax money there is money that goes into we're holding back so many to correct Wendy if I remember correctly we have a fund to finish my comment I just don't feel comfortable voting for this piece again I think I made that clear last year I said that you know unless we have a better picture that we can present as far as why we continue to have both the sales tax and the added bond of all because what was mentioned a moment ago we don't have a 10 million dollars per year bond limit we have an 11 million dollars every two years so there is some understanding with that okay thank you any other questions or comments okay then we're ready to vote and that gave you plenty of time Cheryl to get it up on the board so please push your i or nay button we'll wait for supervisor Bemis as he returns that motion is approved 21 i and 1 nay thank you very much okay ordinance number 8 regarding amending section 72.15 and 72.32 of the shoreline ordinance regarding like michigan setback recommendation 2 and a thank you thank you supervisor damper thank you supervisor damper any questions or discussion seeing no lights no he went a second please push the i or nay button that motion is pretty unanimously thank you very much i'll turn the gavel over to the vice chair resolution is introduced resolution number 20 from the finance committee regarding amending land records modernization plan resolution number 20 is referred to the executive committee resolution number 21 from planning resources ag and extension committee regarding approving acquisition of alliantility corridor property for erect trail development resolution number 21 is referred to the executive committee resolution number 22 from planning resources ag and extension committee regarding authorizing sheboyin county planning and conservation department to apply for resolution number 22 is referred to the finance committee ordinance number 9 from the transportation committee regarding establishing speed zones on county roads j and p town of rye ordinance number 9 is referred to the law committee ordinance number 10 from the transportation committee regarding adding sheboyin county aviation corporation representative to airport advisory committee ordinance number 10 is referred to the executive committee extending the agenda as a motion to adjournment I move to adjourn motion is for adjournment is there a second to raise a winkle second motion second to adjourn all in favor


Hey everyone shape everyone thousand here. I just wanted to say happy Mother's Day to all you mothers out there Hope you're having a great day and thanks for what you do. Bye. Bye guys and take care


So this topic right now is the last topic for a very exhaustive CME for all of you who have been attending since yesterday. Not only because it's a difficult topic, but because this is not these all these pathologies you kind of read, but don't encounter them frequently in your day to day practice. So it's must have been quite exhaustive. So let's, this is the last topic of the day and of the CME is imaging of the hind foot. The hind foot basically would be a boundary between the ankle and the forefoot forefoot is very nicely covered. Let's move to the hind foot. And this I will also include certain pathologies which will not be included in any hind foot or forefoot as such, but will be commonly seen in day to day practice. So the hind foot basically means there is a presence of heel pain or what we call it in scientific terms as calcaneodinia. Now the causes for these would be either auspicious causes, ligamentous causes, tendinous or other soft tissue structures. Radiographs basically show you acute, auspicious abnormalities like fractures, stress fractures and those kinds of pathologies. But MRI could be beneficial in diagnosis and surgical planning. What are the differential diagnosis for heel pain? A lot of differential diagnosis can be possible. Like arthropathies like gout, rheumatoid arthritis, seronegative arthritis or osteoarthritis. Infections could be diabetic ulcers, diabetic osteomyelitis, other causes of osteomyelitis or superficial lesions in the subcutaneous tissues and skin like plantar warts. Mechanical causes could be plantar or posterior, plantar in the form of plantar fissiitis, heel spurs, bony spurs, calcaneus stress fractures, plantar nerve entrapment, foreign body granulomas or posteriorly like achilles tendinopathy, tears, haglens, deformity or haglens syndrome, retrocalcaneal bursitis, tarsal coalescence, accessory muscles or severs disease in the young age group. It can be neuropathic in the form extending right from the lumbar region like lumbar radiculopathy entrapment of the sciatic nerve somewhere in between along its course. Neuromas which are post-traumatic in the foot, tarsal tunnel syndrome, actual trauma cases, rare cases like ewing sarcoma and neuroma, ewing sarcoma just showed in this lecture or post-traumatic neuromas or nerve sheet tumors and rarely vascular causes. So the main causes that we see in day-to-day practice are those associated with plantar fascia, tendons like achilles, FDL, FHL, those related to the calcaneum and to the bursae around the calcaneum. So first we move to the plantar fascia. Now plantar fascia is basically a thickened deep fascia which extends from the base of the calcaneum anteriorly into the different digits. It has three components, the medial cord, the central cord and the lateral cord. It represents the plantar fascia as such when we mean when we don't say medial central or lateral we mean the thicker central component. So it originates from the medial calcaneum fibrosity and splits into five bands for the five toes. The insertion is at the level of the proximal phallus. They are closely adherent to the flexor digitorum brevis muscles at tendon unit. It should not be more than two to four millimeters in thickness and should be low signal on all sequences. So whenever it is more than four millimeters in thickness, it usually indicates the presence of thickening and ultimately leading to plantar fasciitis or plantar fascia degenerative changes. So it's the commonest cause of heel pain. It is also called as heel pain syndrome or subcalcaneal pain syndrome. There are two causes, either repetitive stress or enthesopathy in the form of seronegative spondyloarthropathy. The repetitive stress leads to, now this is an attachment, so this basically is pulling the calcaneal tuberosity towards the anterior aspect. And this stretched out plantar fascia is very important in maintaining the longitudinal arch of the foot. So because of some changes in the mid foot leading to collapse of the arch or a stress with respect to the attachments to the toe, like overuse of the foot for running or these kinds of similar sports leads to repetitive pulling of the plantar fascia along the calcaneum. So what happens is there is spurring or enthesophied formation in this region and that leads to formation of first a fibrous and later an oscious spur. That is also called as calcaneal spur. By definition a painful calcaneal spur will be bony and on the MR will show marrow edema. Thickening of the plantar fascia at this attachment is called as plantar fasciitis. So this is how a normal plantar fascia would look on the axial images and then this is how it would look in an abnormal situation. So in this patient what you are seeing is abnormal thickening more than 4 millimeters of the posterior portion of the plantar fascia at the calcaneum insertion. There is edema in the underlying calcaneum and you are also seeing in this patient a small spur which is going towards the anterior aspect. So this spur also has presence of marrow edema and there is soft tissue thickening and edema surrounding this area of insertion. So all these findings should be together seen for it to be called as plantar fasciitis. Just the thickening of the plantar fascia or just the presence of a spur without marrow edema will not qualify for plantar fasciitis. Just remember that all these findings should be seen together. This case on the top has thickening again this is significant thickening of the plantar fascia with surrounding soft tissue information. So plantar fascia it is when it is related to spondyloarthropathy is usually bilateral. It is associated with Achilles problems like tendonitis and retrocalcaneum bursitis and is also associated with soft tissue and marrow edema. Next when plantar fascia can be either thickened or plantar fascia can be toned. The tear of the plantar fascia can be because of an acute one episode of trauma or it can be because of multiple related micro stress injuries in which the plantar fascia like Achilles tendon first gets degenerated and this degenerated fascia is not strong enough as compared to a normal fascia and can lead to tear because of micro repetitive micro trauma. Now how it would look on the MR is you will see that there is an acute tear of the plantar fascia at the calcineal attachment. In this patient what you are seeing is this in this patient the plantar fascia is relatively normal and it's just tone. So this is probably an acute post-traumatic event whereas in this patient you are seeing that the tone on the retracted plantar fascia the plantar fascia is also thickened and abnormally hyper intense. So this is probably an already degenerated plantar fascia which is just tone from the calcine because of a relatively minor trauma. So on the coronal images again this is your lateral cord and the central and the medial cord of that of this patient is tone because of a tear of the plantar fascia. Distally the tears can occur but is relatively uncommon distal portion of the plantar fascia it is actually thinner than the posterior portion but because the stress of the single attachment is distributed into the five toes it is relatively uncommon to get tone in its distal portion. Most of the tears you will see in the proximal portion. Next is Achilles tendon. Achilles tendon is basically formed by union of the gastronomies and the soleus muscle tendon units into a solitary tendon which is called as the Achilles tendon. The importance of Achilles tendon is it is a big tendon a big in the sense it's a long tendon and it is relatively avascular over a very long length of the tendon. So that's why it is amenable to not only degenerative changes but also tears. It inserts over the posterior aspect of the calcaneum approximately at the level of the mid portion of the calcaneum when you see it from the top to bottom. This, if you see a bony sparring in this region it's basically anthizophyte but some people call it as posterior calcaneum spurs. It is correctly termed as anthizophyte or posterior calcaneal anthizophyte rather than a spur. It is about one centimetres in EP dimension. It is low signal on all sequences and the anterior boundary of the Achilles tendon should be either straight or it should be posteriorly it should be anteriorly concave. It should never be anteriorly convex. So insertion of Achilles tendonosis is the term given to a tendon which is because of repetitive microdrama or underlying degenerative changes can lead to thickening of that tendon and it is usually affecting the distal most portion of the Achilles tendon. So this is just signal abnormality which is not bright enough on PD-FAT side of fluid sensitive sequences to call it a tear. This is an example of thickening of the Achilles tendon at the insertion in the distal most portion. You are seeing hyper intense signal relative to the muscle and the normal tendon on T1 weighted images which is very very slightly bright on the PD-FAT side or stir sequences. And this is not a tear. This is intra tendinous signal with fusiform thickening of the Achilles and is called as tendinosis. When these tendons or a normal Achilles tendon because of significant trauma gets torn it is called as a tendon tear. It can be either micro tears, interstitial tears along the length or across the length of the tendon, complete tears or partial thickness tears. So this is an example of a signal within the tendon on fluid sensitive sequences which is significantly bright. The tendon itself is normal so there is no underlying tendinosis. You can see this interstitial tear in the axial section as well. So what you need to report is the length of the tear and the percentage of the tendon thickness that it involves. This is kind of less than 10% of the tendon thickness is involved along the deep aspect of the Achilles tendon. Overall length of about 1.5 to 2 cm in length and about 1.5 to 2 cm from the calcineal insertion. So all these things you should report in your written report. Sometimes there is a full thickness tear. This is called as a full thickness or a complete tear. Whenever there is a complete tear usually the proximal tendon segment retracts. Here you are supposed to report whether there is the tear that is a complete tear has been there from the insertion. Or there is a short stump of intact Achilles fibres and then it is 7 cm away from the insertion. That is number one. Second thing is how long or how far the tendon, the torn tendon is retracted. And the third important point that you should address is whether this tendon itself is normal or there is an underlying tendonosis. Now this patient if you see there is the tendon appears slightly heterogeneous on T1 as well as BD5 fat set sequences. So this is probably underlying tendonosis and this is the length of the tendon that is retracted. It should have been here. It is retracted by about 4 cm. And this actually involves the calcaneal insertion side. There is no stump of fibres intact seen at the insertion. So as I said we should call it either interstitial partial thickness or complete percentage of the tendon thickness that is involved tendon gap or retraction. EDMOR hemorrhage within the tendon gap. What it is if it is just EDMOR hemorrhage or some soft tissue abnormality which is seen within the gap distance from the insertion. The size of the stump if there is an intact stump and whether the haculent syndrome is present or not in a case of a partial or interstitial pair. Next we move on to the other two tendons which are involved in posterior or hind foot pain. One is FTL and the second is FHL. So whenever there is fluid along the FHL tendon it is usually normal in most of the patients like this amount of fluid however is abnormal. So there is a normal continuation of the tendon sheet of the FHL with the joint space of the pibiotilar joint. Similar to the popliteus tendon sheet in the knee joint and the tendon sheet along the long head of biceps in the shoulder. The FHL tendon sheet also communicates normally with the ankle joint. However presence of a significant amount of fluid along the FHL tendon is definitely abnormal and this can be termed as tinosinoitis. Especially if there is a presence of a posterior ankle impingement as we saw in the last topic or last lecture. Then this amount of fluid is an indication that there is posterior ankle impingement. Then we have retrocalcaneal bursitis which can lead to heel pain. Retrocalcaneal bursitis is usually almost always associated with a problem either in the calcaneum or in the achilles tendon. In this patient you are seeing that there is a hageland kind of deformity in the posterior superior aspect of the calcaneum. You have fluid in the retrocalcaneal bursa. You have some inflammation in the cages fat pad and you have this signal within the distal portion of the achilles tendon. This tendon, this signal is definitely abnormal. It is slightly higher than what you would expect in a tendonosis and the tendon itself is not swollen. So there is no significant tendonosis but this is a partial thickness or interstitial tear. So what do you see on the x-ray is obniteration of the retrocalcaneal fat. In the MR you will see fluid collection within this bursa along with adjacent soft tissue edema. This is another case of hageland syndrome in which you will see this posterior superior process of the calcaneum. Then fluid in the retrocalcaneal bursa, abnormality in the achilles tendon either in the form of tendinosis or a partial tear and adjacent soft tissue edema as well. All of these together will be called as hageland syndrome. If you see only this projection of the calcaneum and no other inflammatory changes you can call it as hageland's deformity of the calcaneum. Other causes in the calcaneum which can give rise to posterior ankle pain or hind foot pain is this kind of this is relatively common in young patients. This is a stress fracture. The stress young patients or a middle-aged female patient who has just recently started running or marathon running. In these patients you will see that there is significant marrow edema in the calcaneum and you start with first a marrow edema. And eventually you will start seeing this linear hyper-intensities on both the sequences indicating the presence of a stress fracture. This stress fracture if it is ignored can lead to this kind of a proper fracture seen on the radiographs. This has to be correlated in a young in not in young patients but slightly middle-aged female patients to rule out osteomyelitis. This osteomyelitis is also quite common in that age group and usually associated with diabetes. Or marrow contusions and sometimes the marrow edema masks the tumors in the calcaneum which fortunately are not very common but they can be missed. Let's move on to the miscellaneous topics leading to hind foot problems. First is tarsal coalition. Now what is coalition? Coalition is complete or partial union between two or more bones either in the mid-foot or in the hind foot. Basically coalition is union of two bones by either a fibrous tissue, cartilaginous tissue or bonnet tissue. So any kind of union is called as coalition. This is usually developmental. Whatever union between the two bones if it is post-infective or post-inflammation it is called as ankylosis. Whenever it is developmental it is called as coalition. So as I said it can be bony cartilaginous or fibrous. The most common in the foot or hind foot is calcaneunavicular or telocalcane. So this is an example of calcaneunavicular coalition. You have the beak sign that you see on the or the anteater sign that you see on the x-ray. You see that the anterior superior aspect of the calcaneum has come together with the calcaneum. The calcaneum has come together with the navicular bone leading to formation of a pseudoarthrosis. So this is a calcaneunavicular coalition. This is a telocalcaneal coalition in which you see a prominent beak here. And when you trace it in the sag you can see only the beak here in the sag reconstruction of the CT also you can see that. But when you actually see the corona lemma you see that these two bones are completely united. Normally you should have a sustentaculum tali over here and the calcaneum which should be seen separately on the medial aspect. And you have the sinus dorsi on the lateral aspect. But in coalition you see that there is trabecular continuity and this is a complete pony union along the medial aspect or that is of the telocalcaneal joint, telocalcaneal coalition. Basically these coalitions not only present with pain but they usually present initially with flat foot. So whenever there is a flat foot you should have two diagnoses in mind. Either flat foot can be a mobile flat foot or it can be a fixed flat foot. Whenever it is a mobile flat foot it usually indicates a problem in the posterior tibial tendon or malfunction or dysfunction of the tibialis posterior. Either the tibialis posterior has tendinosis or a partial tear or an insertional abnormality. Now this can be taken care of by repairing the posterior tibial tendon. The second variety of flat foot is fixed flat foot. This is a kind of fixed flat foot in which you can't really do anything much on this because you cannot reset this bar and make these bones separate from each other. So this is a fixed flat foot deformity. You have to have in these patients you'll have to have shoe correction and posterior changes in the foot to prevent future arthritis. Whereas the mobile flat foot is something that can be eminently treated surgically as well as by footwear modification. Next of hind foot or the heel pain is osteocondrol lesions. Osteocondrol lesions of the taladome as everybody knows is basically the focal area of damage involving the subcondrol bone plate in the initial stages. Subsequently either involving the articular cartilage which is towards the joint or subcondrol cancellus bone which is away from the joint. So the pathology begins in the subcondrol bone plate. If it extends deeper it extends into the subcondrol bone. If it extends towards the cartilage it can lead to presence of this kind of a defect. Then undermines this portion of the subcondrol bone and then ultimately leading to formation of a loose body. So the Anderson's classification basically says that stage one progresses ultimately to stage four in the form of presence of just marrow edema. Then a proper defect extending as a fluid cleft into the overlying articular cartilage with partial separation and then ultimately complete separation. So this is how it progresses and it's called as osteocondrol lesion of the talas. It predominantly affects the medial portion of the taladome but lateral affection is also known. Sometimes what we see is like this we see the marrow edema. Then you start seeing this thin sliver of the osteocondrol bone. This black area is the cortical bone. Small area beneath that is the subcondrol bone. This is partially separated from the underlying talas leading to formation of a partially loose osteocondrol fragment. Now note that this is on the lateral aspect. So this is a lateral taladome involvement by an osteocondrol lesion. This is the sagittal pain in which you are very well seeing this partially separated osteocondrol bone fragment. This also will lead to hind foot pain. Next is presence of ossicles. As I said, ossicles or accessory ossicles around the ankle are very common. There are different books which give rise to more than 10-15 varieties of ossicles around the ankle joint. Are all of them significant? Well, no, they are not significant. But the significance can be found out if there is a pinpoint tenderness over that ossicle. Either that ossicle has undergone direct trauma or because of the ossicle there are some syndromes like osperonium syndrome or ostrigonum syndrome, posterior ankle impingement. Sometimes these syndromes are associated with accessory ossicles. So typically osperonium is an accessory ossicle at the lateral plantar aspect of the cuboid bone. And this is where your peroneal tendons will come over here from the lateral aspect and cross into the soul of the foot. So if there is this ossicle, then it gives rise to repetitive micro trauma to that tendon through the peroneal tendon. And that can give rise to that rupture or tendonosis within the peroneal tendon. So it starts, the causes can be either an acute or chronic fracture of the ossicle itself or tendon rupture or tear, partial tear or a complete tendon rupture. So this is what you would see on a T1 weighted image. You will see that this tend, this ossicle is very close to or almost within the peroneus longest tendon over here on T1 weighted images. On T2 weighted images, what you're seeing is you're seeing an abnormality or a stern hyper intense signal which is traversing all across this length of this inframalular segment of the peroneal tendon. So this is a partial thickness tear and that is what was leading to pain or posterior, posterior lateral pain in this patient. Next, we move on to a couple of infections that are seen in the foot. The commonest, the most typical infection would be Madhura Mycosis which can be given, which has very dramatic effects and unfortunately is very difficult to treat. The commonest one is diabetes, diabetes related osteomyelitis. So what happens in Madhura Mycosis is the patient presents with a swollen foot with multiple sinus tracts and exuding of dark brown or black material from the sinuses. So the clinical triad is draining sinuses, localized mass like soft tissue swelling of the foot and discharging grains of dark material through it. On the MR, the dot and circle sign is what is very, very typically seen. This is the actual image. Now what you're seeing is multiple foots of the bone, multiple bones of the foot are involved in this patient. You have almost disintegration of the midfoot joints in this patient. Whereas in this patient, there is not much of degenerative changes in the bones, but you see that the soft tissues are involved with this kind of soft tissue involvement. This is a PD-FATSAT image showing this dot and circle sign. What you're seeing is you're seeing a bright circle inside that you're seeing a dark dot. So this dark dot is the fungus and this bright area around that is fluid around that fungus or the reactive granulation tissue. On the post-contest images, you see heterogeneous enhancement. Sometimes you can see the dot and circle in the post-contest images as well. This is difficult to identify on the T1 weighted images. The PD-FATSAT or fluid-sensitive sequences and post-contest are the ones that will pick up the abnormality in Madhura Microsis. So whenever you see this, then you are the first one to give an idea that this could be a Madhura Microsis and not a plain and simple osteomyelitis in this patient. So we have a last couple of slides of diabetes-related osteomyelitis, but before that we'll see a couple of other typical cases in the foot. One is called as the joggers foot and one is called as the Baxter's neuropathy. Now what is joggers foot? Joggers foot is involvement of the medial plantar nerve. So the medial plantar nerve is the one that supplies the medial portion of the sole and the location of the abnormality is basically in the Tarsal Tunnel at the knot of Henry. And this gives rise to impingement or compression of the nerve, the medial plantar nerve, leading to abnormality in the flexor halusis brevis. So this is what you see. This is the entire case. This is the T1 weighted image. This is the PD-FATSAT image. This is a PD-FATSAT and this is a T1. Now what you're seeing in this patient who presented with pain basically in a jogger is you start seeing that the flexor halusis brevis muscle is slightly atrophic on the T1 weighted images and is bright on PD-FATSAT images. This entire muscle is bright on PD-FATSAT and shows mild patchy fatty replacement, especially in the distal portion. This is indicative of a medial plantar nerve involvement leading to changes of denervation atrophy, early atrophy and basically degenerative edema in the flexor halusis brevis muscle. What happens on the lateral aspect is called as Baxter's neuropathy. That is entrapment or compression of the inferior calcaneal nerve, which leads to the same abnormalities as you see on the medial aspect in jogger's foot, the same things you see on the lateral aspect in Baxter neuropathy. And what you see is muscle either early changes will lead to hypertrophy and edema and later it will give rise to atrophic changes and further reduction in the edema. So this is the patient in which you are seeing that this on the medial aspect, this is completely atrophic. In the earlier stages, you have this Baxter neuropathy leading to swollen adductor muscle on the medial aspect, adductor halusis. Sorry, adductor digitaminemia on the lateral aspect and this is the one that is bright in the earlier stages leading to atrophy in the later stages. So this is also seen on the sagittal pain you see this is a great three fatty replacement of the muscle. And in the early stages and the acute stages is quite edematous. Tarsal tunnel syndrome is the syndrome which happens because of compression of the neurovascular bundle in the tarsal tunnel that is a posterior tbl neurovascular bundle. It can be either idiopathic or with respect to the SOL in this region can be due to tinoxinovitis of the same tendons. Or bone deformities or hind foot valgus, bone deformities as well as the impingement abnormalities in the tarsal tunnel as we've seen in the last lecture. In flat foot patients, especially further related to the hind foot valgus and ostrigonal. So what you see is your in the course of the posterior tbl neurovascular bundle happens on the medial aspect of the carcaneum. If you see cystic lesions like this, these are related to the tendon sheets. So these are ganglion cysts related to the tendon sheet leading to compression of the posterior tbl nerve. The nerve itself is showing hyper intense signal and is swollen. And that is leading to the posterior tbl nerve impingement and related pain. Whereas I have a confusing name in the same foot is Sinus Tarsus. Sinus Tarsus syndrome is in the lateral aspect of the telar neck.  So this is a portion which is called as the Sinus Tarsus. In the Sinus Tarsus you have multiple structures. But basically what you see on the MR is soft tissue edema and fluid collection in the Sinus Tarsus can lead to can be a result of Proma or inflammatory arthritis and can lead to pain in the central portion of the hind foot leading to Sinus Tarsus syndrome. So you have two different syndromes, the Tarsal Tunnel syndrome along the posterior tbl neurovascular bundle and the Sinus Tarsus syndrome which is more centrally and laterally located in the hind foot. What is Mueller v syndrome? The Mueller v syndrome is now commonly seen and is probably going to become more famous as Nadal syndrome rather than Mueller v syndrome because Nadal is suffering from this disease. What you are seeing is a comma shaped navicular. It's because of osteonecrosis of the navicular along its lateral aspect. So it's usually an adult onset osteonecrosis of the navicular. It's usually bilateral and leads to collapse on the lateral aspect. You need to pick up as radiologist Mueller v syndrome in this stage and not in this stage. In this stage it becomes untreatable. In this stage you are able to pick up the abnormality as marrow edema in the navicular which is dark on T1, bright on pdfatsat or stir sequences only in the lateral portion of the navicular. The medial portion of the navicular is relatively normal. You start seeing that from craniocaudally and from lateral medially. The lateral portion is becoming smaller proximal distally as you progressively see it over a few follow-ups and that is going to lead to collapse of the osteonecrotic portion of the lateral aspect of the navicular bone. Plantar fibromatosis has been seen in the previous lecture by Dr. Ajay is basically a fibrous and collagenous nodules in relation to the plantar aponeurosis or the plantar fascia. It can be either a single one or a multiple one, but the most important thing is it is almost similar to the signal intensity of muscle. It gives intense post contrast enhancement and number three it is very closely related to the plantar fascia. You will not find fibromatosis well away from the plantar fascia. If you see this similar lesion which is away from the plantar fascia, it is very unlikely to be a plantar fibromatosis. So what you see here is a small nodular thickening of the plantar fascia here. Sometimes it's slightly larger. It is kind of infiltrating across the plantar fascia into the underlying muscles of the soles of the foot. It is very, very slightly bright on PD-FATSAC sequences and if you give contrast, it will show post contrast enhancement which is usually heterogeneous. So as again told by Ajay, this is usually amenable to ultrasound guided injections and surgical management of this is not recommended because it gives rise to multiple recurrences. The recurrences themselves become more and more there is more and more scarring along the sole of the foot and they keep on recurring because they are fibrous tissue. Ajay has already dealt with shark coats and just giving you two slides in which we have to differentiate between osteomyelitis and active shark coat. So this is active shark coat and there's one more slide in which there is chronic shark coat. You have basically three types of abnormalities in the foot. One is either because of degenerative arthritis like similar to osteoarthritis. You have osteomyelitis because of poorly controlled sugars and diabetes mellitus or you have shark coats disease which is either because of a spinal cause, any neurological cause or basically because of diabetes related neuropathy. So what you actually have to differentiate is whether it is osteomyelitis because if it's osteomyelitis, the treatment is debridement. You have to reduce the bacterial load in that area to be able to make sure that the sinuses as well as the granulation tissue to form and heal. Shark coats on the other hand is basically a progressive disease in which it basically involves non-surgical management with proper footwear adjustments to the foot and weight bearing and everything. Those things are more important in shark coats because it's basically because of peripheral neuropathy which is leading to collapse of the midfoot because of non-weight bearing area in that region. It is not related to infection but these two usually occur together. The third thing is your degenerative arthritis, whether it is osteoarthritis of the foot. Now osteoarthritis of the foot, even if the foot is a weight bearing area, the area of the forefoot and the midfoot usually are not the areas where you have degenerative neuropathy. The degenerative arthritis or osteoarthritis is basically in the region of the ankle. That is the tibio-telar and the subtelar joints is usually does not involve the midfoot and the distal foot. The distal foot is more involved in goutia arthritis and seronegative arthritis and not in osteoarthritis. So osteomyelitis is usually present with ulcers with heart red foot. The weight bearing areas are the ones that are involved in osteomyelitis because those are the ones which initially become avascular and that avascular coupled with increased blood sugars would lead to sinuses and formation of osteomyelitis. So in the metatarsal phylloengyl joints are the heads of the metatarsals and the calcaneum. These are the two weight bearing areas where you will have osteomyelitis. Whereas in the shark ports, in the midfoot you will have in the subarticular portions and this definitely is not the area of weight bearing. So on the MRI you will have marrow edema in the forefoot and hind foot near the ulcer and here you will have in the subconral bone. When you give contrast, there is going to be heterogeneous enhancement because of the necrotic areas not showing any enhancement. The same necrotic areas will be bright on diffusion weighted images. These abnormalities will not be found in active shark ports. In chronic shark ports, unsuperimposed infection, what happens in chronic shark ports? The midfoot eventually gives in and collapses. This collapsed midfoot again will not be associated with any ulcer the patient will not have pain. The x-rays will show that the foot is terribly abnormal in the form of joint deformity, dislocation, rocker bottom foot but the MRI will not show much marrow edema because it is chronic shark ports. In infection, however, you will again start seeing ulcers now in the non-weight bearing portions because this is now become the weight bearing portion and not the calcane and the head of metatarsals. And this on the x-ray again will be associated with joint deformity, dislocation and rocker bottom foot but you will start seeing marrow edema in the cuboid or other weight bearing areas near the ulcer. So this is the shark port with superimposed infection which again will need debridement and not just non-surgical management as you would do in a shark ports. Couple of examples on the MR. This is a patient in which you are seeing a deep ulcer over here. You are seeing marrow edema in the calcane. There is almost complete soft tissue loss in this region with these changes in the calcane. Now this is a weight bearing area. You have the ulcer, you have edematous changes in the rest of the foot. So this is definitely an infection or infective osteomyelitis rather than a shark. So let's move to a few cases. So are you able to see the images? Yes, sir. Okay. So this is the sagittal PD-FATSAT and this is sagittal T1. Now what you are seeing in this patient is you are seeing an achilles tear obviously but what are the findings that you will see in the report? Now this is a full thickness tear from the insertion. There is retraction of the tendon by whatever four or five centimeters. The underlying tendon appears abnormal. It is thickened on T1 as well as PD-FATSAT sequences with heterogeneous signal within. So this is an underlying tendinosis within the retracted tendon. There is no maroedema in the underlying calcaneum. What you are seeing over here is your, this is the enthesopathy that you are seeing. This is the new bone formation along the distal aspect of the achilles tendon. So this is achilles tendon enthesopathy with tendinosis and a full thickness tear with retraction of the torn tendon end. Now this is the next case. In this, what are you seeing? You are seeing that there is maroedema in the region of the calcaneum which is bright on PD-FATSAT sequences. Not appreciated on the T1 weighted sequences. And what is happening to the plantar fascia? Plantar fascia is thickened and shows subtle signal abnormality as it approaches the insertion. So this is, there is also presence of edema in the adjoining soft tissue. So this is plantar fasciitis. In the same patient, what you are seeing is, you are seeing abnormality in the achilles tendon which is slightly bright as compared to what you would see in a normal tendon. This is definitely quite bright. So this is a partial thickness interstitial tear of the achilles tendon in the same patient. And what you are also seeing here is your prominent steada process. So this is the prominent steada process. But as you saw in the other slide, now this is the FHL tendon which is crossing the steada process. And then going here, this is minimal fluid. So this much fluid is okay along the FHL tendon. The amount of fluid that you saw in the other, in the PowerPoint presentation was significantly more. So that is abnormal. This is, that was FHL tinocynometers. This is normal. Now this was a diabetic patient. Now this is in 2016. And in this 2016 patient, what you're seeing is that you're seeing an ulcer over here. There's a focal soft tissue loss on PDFATSAT and T1 weighted images. You see very subtle abnormality in the calcaneum and the cuboid. But you don't see really any floated osteomyelitis in this patient. You're just seeing soft tissue changes in the form of edematous soft tissues, which are dark on T1 and bright on PDFATSAT sequences. So what happens when you follow up the patient? Then in 2018, this is what happens if the diabetes is ignored. You have involvement of the bones here. So you have involvement of the talus, distal end of the TPR, calcaneum, the navicular, the cuboid, even the cuneiforms. All of them show the signal abnormality, just dark on T1, right on PDFATSAT sequences. And what happens when you give contrast in the same patient? You see that there is heterogeneous enhancement. You see some areas which are enhancing, some areas which are not enhancing. So for example, in this portion of the talus, if you're seeing this dark area on T1, it's not showing any enhancement. This central portion is showing enhancement. Some portion is not showing enhancement. So you have the granulation tissue which is showing enhancement and the necrotic portions of the bone which are not showing enhancement. The ulcer is still seen in this patient. So when you give contrast, what you are seeing is this is a case of diabetic osteomyelitis. Eventually what has happened over the two years is there is progression of the soft tissue infection into the bones and there's also presence of early rocker bottom foot. This midfoot and the high foot both are collapsing. So this is an advanced case of diabetic osteomyelitis over the period of two years. So this luckily we got this case in which we could show you what was happening two years back and now what is the current status in 2018. The rest of the cases I've already covered in the presentation. So we are...


Get your boat, man, we're going on a boat. I still need to get all this cleaned up. Maybe I can do this today if we're not gonna board, get rid of all these wires and stuff. That's for my dash camera up there. For some reason, Peterbilt, these new Peterbills don't have a plug-in up here like most other trucks do for the dash camera. At least I haven't found it yet, if it does. So I got all the plug-in down here. So they're moving over there already. I still have all these trucks in front of me yet. And they told me last night when I was boarding that I probably won't be getting on this ship. But this ship was supposed to leave last night, but it got delayed because of weather. So I don't know if they have two ships going today because there's two ships here right now. Now I don't know what's going on, but for those of you just tuning in, you missed yesterday's video and all the other ones before that, we're on our way to Newfoundland in Canada. It's an island off the East Coast. It's our eastern-most province. Newfoundland and Labrador. And it's an eight-hour ferry ride from the mainland. So we're on our way over there. Haven't been here in a few years. I'm actually really excited to see if anything's changed. We do have a cabin on board so we can go to sleep. Once we get on the ship again, we have to stay in our cabins the whole time because of the whole coronavirus going around right now. So we can't really move around the ship at all. I'm also asked to wear a mask. So good thing I have one. I'll call them on the ship in the public areas, at least. And yeah, glad you're here. It's going to be an interesting day. I'm just waking up. I've got to be ready just in case if they tell me to board. A lot of guys want to get on here though. There's a lot. Not too many cars though. I mean, because travel's not really a thing right now, right? So everyone on the island is sort of staying on the island unless they have to leave and no one's really going to the island unless they have to go to the island. Like us. So it's mostly just commercial trucks. Mostly. They got the next line to our left here all boarded. Well, they've got three ships here now. They're loading the ship off to the left, right over there. I just realized that now. That's the smaller one. Okay, so if we don't make it on that one, we got to go on the fancier one, I think. I think they're going to start on our line next. So I'm going to have to be ready to move up right away. Where's my hat? Oh, I can't board without my hat. This truck is so big I can't keep track of where everything is. I still haven't organized anything. It's just been go, go, go ever since we got into the truck. So I guess maybe once we got to wait on the island or if I got to wait all day today, I may have some time to organize yet, but I have to go through everything up on that shelf and it takes me a while to fully settle in to give everything its rightful spot in the truck, right? And then I have to remember where I put the rightful spot for everything. Oh, I think they took one more for a mile. I might get on this ship yet. I would like it if I could. I would really like it. I don't really want to wait here all day for the next one. This doesn't make sense because these guys on the right got here before me. Maybe they're a, I thought someone was honking at me. What do I do now? Okay, now they're taking these guys off to the right. This guy can't stay between the lines. I don't blame them. They make these lanes so narrow. Gonna have to take these flat beds first, I think. I mean, if they're going by arrival time, they all got here before me. Easily excited, going on a boat. Us prairie boys, look at us go. Going on the big, bad ocean. Nervous, I don't like water. I don't like open water. I don't like view. That's why I live as far away from any ocean as possible. Everything in the ocean wants to eat me, in my mind. Got us a window cabin this time. Look for ourselves, which is awesome. Look at me, look all goofy, but that's all right. I like this mask, I think it looks better than some. Do what we gotta do, right? So now that I'm in my cabin, I can take that off. So usually when I'm on the boat, I have to share it with another driver. So there'd be two of us in here. It's a pretty close quarters, right? Sharing a room like this with a stranger you've never met before, that most likely snores like crazy. Every time I've been on this boat and had to share a room with another driver, they've been a snorer, everything. But now, because of the virus, one of the good things, I guess, if you can call it that, we each get our own cabin, no sharing. That makes sense, right? And I like that.  Second of all, this is all mine now. And we've got a window. I've never had a window before. What's this? Can you open it? Does it not come back down?  Wow, would you look at that? Fancy. So it's like a little tiny small floating hotel room. You can fit up to four people in here. You can pull these down and... Sort of feels like you're in third class of the Titanic, right? Pretty much. I don't know how comforting that comparison was, but we'll be okay. I'm a prairie boy. I'm from, I live in the center of the continent, far away from any oceans. Poses, he runs and beer seat, we'll be able to come back. There you are. I was wondering where that was coming from. I'm hearing voices. You heard that too, right? Anyway, so while I'm in here, they gave us a lunch. Because they don't sell lunch anymore. So they gave me a free lunch. Wanna see what they gave me? Let's see. Oh, a muffin. Very nice, very nice. Water. Very nice. Oh, another water. Very nice. A sandwich. Oh, these are the expensive package sandwiches too. Very nice. What's he got? Oh, any dessert or anything in here? Oh, look, they care about my health. They gave me an apple. Very nice. Set that all up there in this little display. There you go. Hold on a second. Napkins? No dessert. That's okay. They didn't have to do this. Usually you gotta pay for your meals on board. You can go in the restaurant and buy your meal, but since the whole virus, I'm not allowed to leave this tiny little hole. This is my little pigeon hole for the next eight hours. So, they gave me some food so that I, I guess so that I don't emerge from my hole and start wandering around in search of food.  I got some elbow macaroni salad. Just add this to the little pile over here. Very nice. What else do we got? I brought some waters too, so I have lots of water. Add this on. Very nice. What else did I bring? That's all I brought. I brought my computer. Oh, oh, I brought fruit cups. So here you go. This'll be for breakfast and lunch. And by supper, we should be on the island. Very nice. And I'm gonna edit some videos and stuff while I'm here. That's why I've got the computer. And also, don't worry, we have our own bathroom. And turn the light on. Oh, there's that ugly guy again. He follows me everywhere.  Creepy, right? They need to wash their boats. So that says the Atlantic Vision. And there's another one on the other side of that. Yeah, I think this one right in front of us here is the nicest one. The last time I saw it though, it didn't have all those rust stains on it. Just in case. I can even watch TV. Oh, there's a remote. For my viewing pleasure. Huh, America. Is that you? You hear that? So if I want to, I can just have this soothing music on in the background. Well, I guess serenaded with the American flag. I don't know what channel this is. Do they have other channels? Oh, they do. I don't wanna look at Trudeau. TLC, huh? Oh, we're moving. Whoa! Freak me out. We're officially moving. We are floating on the water. On the ocean. That's the ocean down there. There it is. You know, we're moving along. Oh boy. I think we'll be okay. We've done this voyage many times before, but every time it's like, that's a lot of water underneath me right now. In light of the global pandemic related to COVID-19, the government of Canada in cooperation with provincial, territorial, public health authorities has put basic important measures to help spread, help limit the spread of COVID-19 in Canada. Please be advised that many provinces and territories are asking travelers with some exceptions for essential services to self-isolate and monitor themselves for symptoms to help limit the spread of COVID-19 in Canada. Travelers are reminded to stay informed about COVID-19 measures and apply in a region where you're traveling and update updates from their national, provincial and territorial health authorities. Thank you. No re-attention. It's a little bit planned up. The next message, we're going to get back to you. Yeah, boo, boo. All right. Oh, look at me. I'm even uglier than I remember. Yes, I need a haircut so badly. I hope the barber shop's open when I get back home. Look at this. I don't even have much hair to run my hands through anymore. I'm getting pretty bad. Land ho! That was about the fastest crossing I think I've ever experienced. It was like five and a half hours. It was supposed to take eight. We're just giving her. So I have to wear this outside my room. Makes them feel better. I don't mind. Whenever, as long as they let me on their boat and let me deliver my stuff, it's all that matters. So I'm waiting for them to come to my room right now. I can't leave here until I'm told I can leave. It is what it is. Just gonna follow along and play along with their rules. Weasel, how was the ride? We very well needy, man. Here we go, I'm so glad you're back. Glad I'm back too. Wish I could bring you up with me, bud. But Marine Atlantic does not have a very good pet policy. I would say that's a topic for another time. Let's just talk for another time. Those of you who know me know how I feel at Marine Atlantic and their pet policies. I would say they borderline on animal cruelty. But we'll talk about that another day. We made it. And it was a fast crossing too. And the temperature was great, so no problem at all. No problem, Ray Dezo. I felt like you were going a million years, man. I was so excited when you came back. You were sleeping, man. You didn't even realize me getting in the truck. I was already in the driver's seat by the time you realized and like did a backflip. I was so excited to see you. Yeah, showered me in dog kisses. He seriously acted like I was gone for a million years. He just calmed down now. Looks like we're all getting ready to leave here though. So I guess I should get in the cockpit here and sit down and get ready.   So that guy goes next. Look at that nice tarp job. So glad I don't gotta do that anymore. I did that for long enough. It was fun, not all the time, but I think this tanker guy's gotta go next. Oh, that tanker first. Okay, that tanker guy and then this tanker guy and then me I think. Oh, wait, that car is trying to bust in front of everybody. You gotta listen to the people. They're directing who can go and who can't. This one's gonna let him go. This guy and then me. I think they're gonna point at me next. I'm gonna let these cars go first probably. What are they doing, diesel? They're directing traffic, mate. Very discerning, very discerning. It's okay, diesel. It's okay, they're okay, they're friends. Wave through. Guess I should put it in gear first. There we go. Jumpy clutch. I'm gonna scare people here. So getting used to this clutch. That clutch, so I don't have as much control over it already as I would like to have. Little bit jumpy. We're gonna get off the ship here and welcome to Newfoundland and Labrador, but it's Newfoundland. Labrador's on the mainland. For some reason, they're one province. Oh, and it's raining. Oh, of course it is, glorious. Okay, why are they stopping down there? See, all of these guys, all of these cars, they gotta go through, or is it all of us? We all gotta go through a special screening. I thought that commercial drivers got to bypass that screening. I guess not. I don't know what's going on. I know it's raining though, and that makes me sad. This guy here, I guess he'll direct me. He's gonna go in this lane here.  Do I go past here? Right on out, okay, thank you. Look at all these people, look at me. Look at me, I'm essential. I don't gotta stop for any of this. I just go right on through. Double check, make sure nobody weighs me in here. Essential. Ever felt so important in my life. I'll deliver some stuff and come back. I'm guessing now that we're here so early, a lot earlier than I thought we would be, we'll probably get unloaded today yet, and then be right back here waiting for the ferry, the same one, to go back to the mainland. They didn't serve me coffee on the boat. Gave me free food though, so that made up for it. You guys are watching from Marine Atlantic. Thank you for the free food, I appreciate it. I still don't like your pet policy.


Hello there everyone and welcome. This is Melissa Armo and I own the stocks whoosh. And I wanted to address a concern that some people have mentioned to me recently. And it's something that people have mentioned to me in the past, but it's become more and more evident that one of the reasons that people don't do well trading is because they are so scared that they're gonna be able to do it on their own. And one of the nice things about my system is that I teach people how to do it on their own. If you want to, that's true. But I also have the live trading room Monday through Friday. So the room is a support system. For you as a trader, you can join the room after you learn my system, after you take the bullet gap course and you can be in the room and you can take the trades which I'm calling live. So that helps you. It helps you become profitable right after the class and it's a support system. Also I'm mentoring people, talking to them in Skype, talking to them in emails, talking to them in the phone, answering questions for people if they have questions after the class and they wanna review something with me. I make myself available to people for that to help mentor them through the process. So many people are afraid that they are gonna take the wrong trades, that they're not gonna be able to do it. People believe that I can predict everything that's gonna happen in a chart but they have a hard time believing that they will be able to predict where stock's gonna go. And therefore people get scared to take the trade but you can't be scared to take a trade. You have to believe that you can do it. So how do you instill that confidence in yourself? I call it conviction.  You establish that confidence in yourself by learning the information and following me and listening to me in the live trading room and taking the trades and gathering up the profits. Green, green, green, green, green. The consistency by listening to what I'm saying, taking the calls, green, green, green, green. Nothing like helps your confidence than having a series of green gaze and becoming consistent. It really helps you. A lot of people are just afraid. They're just afraid to do it. Maybe they're afraid because they traded in the past and lost money in the market. Maybe they're afraid because they've never traded at all. I'm telling you, you can't be afraid to trade. You can't be afraid to do this. I will help you because if you come to me and you learn my class, I'm gonna help you. I take it seriously, people that come and want my help. That's why I'm charging for my time in the class and all the things that I offer people outside of the class in my free time to try to help people make it. You have to decide if you wanna trade or not. That is something that I can't decide for you that is 100% your decision and up to you. But don't not trade the market because you're afraid that you can't do it. I'm helping people do it. I am. And the fact is that after the class, I don't disappear. I'm there in the live trading room if you wanna join it. I'm here in the phone if you wanna call me if you have a question for me. I can help you mentor you through this process to learn it until you do it. And you can listen to me daily in the live room and take the calls. So think about it. Gaining confidence in yourself is something that many people find challenging in the market, but you've gotta do it if you wanna be successful. Otherwise, don't trade. A lot of people trade the market and they have no confidence in themselves and they don't follow the system or they don't have confidence in the system that they're following. That is crazy town, okay? Don't trade if you don't have confidence or a system. You've got to learn my system if you wanna learn it and you will gain confidence through doing it and seeing a series of green profitable days. Listen to me in the room is the best advice I give to people when I'm lecturing and listen to me and everything I teach in the class. Have a great day everyone. If you're interested in the next Golden Gap course, email me at melissa at thestockswish.com.