text:
Saclarides, N, Glob. libr. women's med.,
Common Anorectal Problems
Nadine L. Saclarides
University of Surgeons, Rush University Medical Center, 1725 West Harrison Street, Suite 810, Chicago, Illinois, USA
ANORECTAL ABSCESS
ANAL FISTULAS
RECTOVAGINAL FISTULAS
PERIANAL HIDRADENITIS SUPPURATIVA
PERIANAL CONDYLOMA
Women frequently describe symptoms of anorectal disease to their gynecologist. These symptoms may coexist with pregnancy or pelvic floor disorders, or may occur independently. The most common symptoms are pain and bleeding with defecation, but may also include itching, drainage, and fullness from a mass (e.g., external hemorrhoid). These are most often attributed to benign disorders (e.g., hemorrhoids, fissures, abscesses), and a careful history and physical examination will help identify the source. Diet and lifestyle changes can ameliorate symptoms from fissures and hemorrhoids, but the patient with persistent symptoms or a more complicated entity may require evaluation and possibly surgical intervention by a specialist.
The anal canal is approximately 4 cm long and embryologically originates from proctoderm fused with the rectum (derived from the hindgut). Its caudal-most margin is the anal verge, marked by corrugated skin. The lower 2 cm of the anal canal is lined by the anoderm, a thin stratified squamous epithelium that lacks hair follicles, sweat or sebaceous glands. Approximately 2 cm above the anal verge is the dentate line, where anal valves and crypts house primitive anal ductal glands. Longitudinal folds of mucosa just above the dentate line form the columns of Morgagni. A transitional zone of cuboidal cells approximately 1 cm above the dentate line marks the vergence with the columnar mucosa of the rectum (Fig. 1).
Fig. 1. Anatomy of anal canal. (Marcio J, Jorge N: Anorectal anatomy and physiology. In Beck DE, Wexner SD [eds]: Fundamentals of Anorectal Surgery, p. 5, 2nd edn. London, WB Saunders, 1998)
The anal sphincter is composed of two muscles. The internal sphincter is involuntary and is a continuation of the circular smooth muscle of the rectum. The external sphincter is a continuation of the striated muscle of the puborectalis muscle. The anorectal ring is a muscular structure at the junction of the anal canal and the rectum. It includes the puborectalis sling and upper portions of the internal and external sphincter (Fig. 2). Division of the anorectal ring results in incontinence. Blood is supplied to the anorectum via the superior hemorrhoidal artery (branch of inferior mesenteric artery), middle hemorrhoidals (branch of hypogastrics), and inferior hemorrhoidals (branch of pudendal artery). The anoderm and perianal skin are the only areas with somatic innervation. The upper anal canal and rectum are insensate.
Fig. 2. Relationship of external and internal sphincter, coronal view.(Marcio J, Jorge N: Anorectal anatomy and physiology. In Beck DE, Wexner SD [eds]: Fundamentals of Anorectal Surgery, p. 6, 2nd edn. London, WB Saunders, 1998)
The fascial compartments surrounding the rectum are complex but clinically important. The rectal fascia propria surrounds the rectal wall and envelops the neurovascular supply and lymph nodes to the rectum. In women, the anterior rectovaginal fascia attaches to the vagina, forming the pouch of Douglas at the level of the superior vaginal recess. Relaxation of this fascia contributes to rectoceles and posterior support defects. Posteriorly, Waldeyer's fascia covers the presacral space. Laterally, the visceral pelvic fascia surrounds the mesorectum, is fixed superiorly to the internal iliac artery and hypogastric plexus, and forms the lateral rectal stalks (Fig. 3).
Fig. 3. Relationship of perirectal fascia in women. (Godlewski G, Prudhomme M: Embryology and anatomy of the anorectum. Surg Clin North Am 80(1):319, 2000)
Examination of the perineum can be performed in several patient positions (e.g., prone jackknife or left lateral decubitus with the knees bent toward chest), but is easily performed while the patient is in the lithotomy position for a pelvic exam. Inspection should include the entire perineum, noting asymmetry, masses, or skin changes. Condyloma, thrombosed or prolapsed hemorrhoids, anal skin tags, or fissures can be identified from external inspection. Induration or drainage suggests a fistula or abscess.
Palpation is used to evaluate tone of the anal sphincter, masses, tenderness, and induration. The tract of a fistula may be palpable and pus may be expressed from its external opening. In general, hemorrhoids are palpable only when thrombosed. The cervix is easily palpable, and tampons should not be mistaken for rectal masses. A bidigital examination to evaluate the rectovaginal septum should be performed, especially for patients with known or suspected cancer. The coccyx and ischial tuberosities can be identified and used as reference points to describe the location of a palpable lesion.
Anoscopy is the best method by which to inspect the anal canal for lesions near the dentate line. Fistula openings and internal hemorrhoids can be identified. If no identifiable lesions are found to explain rectal bleeding or pain, then rigid proctosigmoidoscopy or colonoscopy may be warranted. Patients 50 years of age or older should undergo screening for colorectal cancer, even if a benign anorectal problem has been identified.
Symptomatic hemorrhoids are a common problem, believed to affect close to 25% of the American population.1 Most commonly occurring in the fourth to sixth decades, hemorrhoids may affect patients of all ages. They may be exacerbated by the hormonal changes of pregnancy, and may or may not resolve postpartum.
Hemorrhoids are vascular cushions that become congested with increased anal, rectal, and abdominal pressures. They are ubiquitous in the general population and the degree to which they cause symptoms depends on the integrity of their supporting connective tissue framework. Hemorrhoids are classified as internal (above the dentate line and covered by anal mucosa) or external (below the dentate line and covered with anoderm or perianal skin) (Fig 4).
Fig. 4. Anatomy of internal and external hemorrhoid. (Marcio J, Jorge N: Anorectal anatomy and physiology. In Beck DE, Wexner SD [eds]: Fundamentals of Anorectal Surgery, p. 239, 2nd edn. London, WB Saunders, 1998)
On physical examination, they are typically located in the right anterior, right posterior, or left lateral position. Internal hemorrhoids usually present with bleeding associated with defecation and a sense of fullness from prolapsed tissue, which may require manual reduction. Pain is present only if an external hemorrhoid is thrombosed. Acute hemorrhoidal prolapse can be exquisitely tender, producing irreducible edematous tissue. Pressure necrosis, ulceration, and secondary infection can occur. Differential diagnosis includes painful bleeding from an anal fissure, full-thickness prolapse or procidentia, anal skin tags, and thrombosed external hemorrhoids.
Internal hemorrhoids are classified into four categories. First degree hemorrhoids project into the canal and cause bleeding, but do not prolapse. Second degree hemorrhoids prolapse, but spontaneously reduce back into the canal. Third degree hemorrhoids must be reduced manually, and fourth degree hemorrhoids are irreducible. Treatment for hemorrhoids ranges from dietary and lifestyle changes to surgical excision, and depends on the severity of symptoms and response to conservative management. For mild to moderate symptoms, a high-fiber diet and bulk dietary supplements can help alleviate pressure and bleeding. Patients should be encouraged to drink water and defecate without delay at the urge sensation.
Several procedures have been developed to fibrose the hemorrhoid tissue onto the underlying internal sphincter, thus restoring support for these vascular cushions and thereby preventing prolapse. When dietary and lifestyle modifications fail to reduce symptoms, sclerotherapy, rubber band ligation, and coagulation techniques may avoid surgical hemorrhoidectomy in up to 80% of patients with first and second degree internal hemorrhoids.
Sclerotherapy is effective in 60–80% of first and second degree internal hemorrhoids. It can be performed easily in the office and is relatively painless. Sclerosing agents, such as quinine and urea or 5% phenol in vegetable oil, are injected at the base of the hemorrhoid above the dentate line. Rare complications include sloughing of the mucosa, reaction to the injectate, and secondary infections. Sclerotherapy is not as effective on large prolapsing hemorrhoids.
Rubber band ligation of first and second degree hemorrhoids is effective in 65–75% of patients.2 Although less effective with third degree hemorrhoids, it can still be considered if one is attempting to avoid surgery. Banding around the base of the hemorrhoid causes necrosis and sloughing, and subsequent ulceration and fibrosis of the mucosa fix the tissue to the underlying sphincter muscle, preventing sliding of the anal mucosa. Banding is a simple procedure that can be performed in the office setting, and is relatively painless if performed properly. Common complications (less than 5% of patients) include bleeding, secondary infection, and pain if the band is placed too close to the dentate line. Despite rare reports of sepsis, rubber band ligation is one of the most common modalities for treating hemorrhoids.
Infrared photocoagulation transmits infrared radiation and coagulates the mucosa, with results similar to banding and sclerotherapy. If done properly, it also is relatively painless and complications are minimal. Laser photocoagulation offers no advantage over other treatment modalities as it is expensive and carries a greater risk of complications from unrecognized deep tissue destruction.3 Electrocoagulation employs thermal injury to fibrose the hemorrhoidal tissue. Bipolar electrocautery employs similar instrumentation as the endoscopic devices and can be applied through an anoscope. Direct current electrotherapy requires more time and discomfort, but has shown better results in treating fourth degree hemorrhoids.4 A heater probe modified for use through an anoscope also shows good results with first and second degree hemorrhoids, but requires interval treatments.
Reducing increased anal sphincter tone, and thus preventing engorgement of the vascular cushions, is the theory behind anal dilation and sphincterotomy. Manual dilation traumatically disrupts fibrotic bands and sphincter muscle fibers that contribute to increased anal tone. The procedure must be done under anesthesia, and while having success rates comparable to other nonoperative treatments for patients with high intra-anal tone, it carries almost a 10% complication rate. Complications include mucosal tears, prolapse, and incontinence. Surgical sphincterotomy also reduces high canal pressures, but is usually performed in conjunction with other procedures and is generally not performed as the sole treatment modality for hemorrhoids. The internal sphincter is partially divided under direct visualization, thus reducing anal pressure in a more controlled and predictable fashion than anal dilation.
Surgical hemorrhoidectomy is indicated for grade 3 and 4 hemorrhoids and for patients with grade 1 and 2 hemorrhoids who have failed conservative management. One or all three hemorrhoidal complexes can be removed, generally in the operating room under local anesthesia. Hospitalization can be avoided for many patients. The swelling and discomfort of surgical hemorrhoidectomy requires a longer recovery period (minimum of 2 weeks) but, with a recurrence rate less than 3%, offers cure for most patients. Complications include bleeding, urinary retention, anal stenosis (less than 1%), and abscess or fistula (less than 0.01%).5 Surgical hemorrhoidectomy can be performed in combination with other modalities, including sphincterotomy, banding, and sclerotherapy and can be tailored to the individual patient. Several trials have compared laser excision of hemorrhoids with surgical excision; clear improvements in postoperative pain, analgesia, or recovery time have not been demonstrated with laser hemorrhoidectomy. Moreover, the added cost and delayed complications of bleeding, stenosis, intersphincteric abscess, and prolonged healing from laser excision leaves surgical excision the gold standard of hemorrhoid treatment.3
Newer surgical techniques include stapled hemorrhoidopexy or procedure for prolapsing hemorrhoids, which was first developed in the 1990s. Stapled hemorrhoidopexy is performed using a circular stapling device which is inserted into the anal canal. A purse string suture is then placed into the mucosa, approximately 2 cm above the superior aspect of the hemorrhoids. The opened stapler device is inserted into the purse string suture, which is then tightened. Next, the stapler device is closed and fired, thereby excising a ring of hemorrhoidal tissue. The results of this mucosectomy is thought to be twofold, both reducing the prolapsed anal mucosa and disrupting the vascular supply to the hemorrhoids.6 This procedure, when compared to the conventional excisional hemorrhoidectomy, is found to cause less postoperative pain and fewer complications from bleeding with comparable recurrence rates.7, 8
Doppler guided hemorrhoid artery ligation (DGHAL) was first described in 1995 by Morinaga and has since gained in popularity, especially in Europe. DGHAL is performed using a modified proctoscope which is combined with a Doppler probe. This is inserted into the anal canal and used to identify the hemorrhoidal arteries. Sutures are then placed into the areas of arterial signal through an opening in the proctoscope. This both ligates the arterial supply of the hemorrhoids and pexies the mucosa, reducing prolapse. Sohn et al. followed a cohort of 1415 patients for two years after being treated by DGHAL. Their experience found this procedure to be less painful than traditional banding secondary to the suturing occurring above the dentate line with fewer hospitalizations and less time off of work. Relatively few complications were encountered, but did include infection and hemorrhage, both with rates of less than 1%. Recurrence rates also were not significantly different than those found with excisional hemorrhoidectomy.9
Hemorrhoidectomy should not be performed in the presence of local perianal inflammation or dermatitis. Patients with ulcerative colitis should be treated only while in remission. Caution should be exercised for patients with Crohn's disease as well; if the patient has active anorectal Crohn's disease, then hemorrhoidectomy wounds may not heal. Hemorrhoidal flare-ups during pregnancy can be treated conservatively in most instances; however, grade 4 disease can be surgically treated during all three trimesters with acceptable results. Patients with AIDS may safely undergo hemorrhoidectomy, provided their immune status is stable.
Anal fissures are very common, and initially appear as an acute tear in the mucosal lining of the anal canal below the dentate line. Often precipitated by a hard bowel movement or diarrhea, patients complain of intense pain associated with defecation and bright red blood on the toilet paper. Symptoms resolve in a few hours. Patients often mistake their symptoms for hemorrhoids. The pain may be so severe that patients hold their stool as long as possible and refuse examination unless under anesthesia. On examination, anal fissures are most commonly located in the posterior midline, with approximately 10% located in the anterior midline. Any deviation from these anatomic locations should raise suspicion for another disease process (e.g., inflammatory disease, venereal infection), especially if the lesion is nontender or located above the dentate line. Hypertrophic anal papillae are associated with chronic anal fissures and are found internally at the dentate line; a sentinel tag or pile often marks the fissure externally at the anal verge. Fibers of the internal sphincter may be exposed at the base of the ulcer and are friable on examination. High anal sphincter tone fosters nonhealing, which is further exacerbated by relative ischemia of the posterior midline anoderm.
Treatment of anal fissures is aimed at relieving trauma and relaxing anal hypertonicity. The addition of bulking agents and dietary fiber should improve symptoms in 4–8 weeks. A local anesthetic ointment, such as 5% lidocaine, applied at the time of defecation helps relieve painful symptoms. Warm sitz baths relieve perineal pain, trigger the somatoanal reflex, and have been shown to relax hypertonic sphincter tone.[10] Application of glyceral trinitrate 0.2% ointment (nitric oxide donor) has been shown to increase anoderm blood flow and relax sphincter tone.[11] Healing of fissures has been noted in up to 60% of patients, with side-effects including headache and orthostatic hypotension. Initial optimism with glyceral trinitrate has waned, and some prospective randomized trials have shown no benefit in pain scores or rate of healing when compared with dietary fiber and bulking agents alone.[12] Botulinum toxin injected into the internal anal sphincter relaxes anal resting pressures by binding to the presynaptic cholinergic receptor. In patients with chronic anal ulcers not responding to conservative management, 86–100% responded to botulinum injection. No adverse effects or permanent sphincter damage was noted, and the effects of botulinum toxin reverse in 3 months.[13] It is reasonable to try conservative therapy with glyceral trinitrate or botulinum toxin; however, patients should be told that treatment may not be successful or the fissure may recur. Furthermore, some patients are so miserably affected by the rectal pain that several weeks of conservative therapy is not an option.
Manual dilation and relaxation of the anal sphincter under anesthesia can be performed; however, the extent of traumatic rupture of the internal sphincter muscles is unpredictable. Consequently, this treatment has not gained wide acceptance. Surgical lateral sphincterotomy remains the gold standard for release of high anal sphincter tone and treatment of chronic anal fissure. Performed under local anesthesia, the internal sphincter is divided from the dentate line to its distal most margin at either lateral position. This can be performed using either an open or closed technique (Fig. 5). To avoid fistula formation, the anoderm and subcutaneous external sphincter should not be violated. Fissurectomy can be performed at the same time. Success rates are high and recurrence rates are less than 5%.[5] Complications include incontinence of flatus and soiling (less than 15% of patients).[14] Fortunately, these complications are temporary for most patients who experience them.
Fig. 5. Lateral sphincterotomy techniques (left, open; right, closed). (Fleshman JW: Fissure-in-ano and anal stenosis. In Beck DE, Wexner SD [eds]: Fundamentals of Anorectal Surgery, pp. 214–215, 2nd edn. London, WB Saunders, 1998)
Abscesses in the anorectal tissue spaces are believed to arise from infected anal glands in a crypt at the dentate line. They can also be associated with recent trauma, surgery, or a complication of fissures and hemorrhoids. Patients with Crohn's disease, diabetes, or hematologic or immune disorders are more likely to develop perirectal abscesses. A careful history of other constitutional complaints is important, as a perianal abscess may be the initial symptom of inflammatory bowel or another systemic disease. Patients usually present complaining of a constantly painful mass and often fever. Walking or sitting may exacerbate the tenderness. The pain is relieved promptly with drainage (either spontaneous or surgical). On examination, superficial abscesses will be indurated, erythematous, tender masses. Deeper abscesses may be palpated as a tender boggy mass on digital rectal exam; however, the exam may be deceivingly unremarkable. A high index of suspicion is paramount to avoid misdiagnosis. If the exam is unclear, MRI, endoluminal ultrasound, or CT scan may aide in diagnosis. Many abscesses are associated with a fistulous tract or go on to develop a fistula, and a thorough exam can help identify those patients who may need a fistulotomy. Hidradenitis, pilonidal sinus, Bartholin's gland abscess, and malignancy are in the differential diagnosis, as all of these entities may present with erythematous tender perianal masses associated with draining tracts.
It is thought that perianal abscesses spread through the internal anal sphincter into various potential anorectal spaces. Most commonly, abscesses lie superficially beneath the perianal skin and can be easily drained through a small incision. Deeper abscesses can develop in the ischiorectal fossa, intersphincteric or supralevator spaces (Fig. 6). Multiple compartments can be infected, and if the deep anal space is involved, horseshoe extensions can develop into either ischiorectal space. In rare cases, life-threatening Fournier's gangrene can develop; this is a polymicrobial necrotizing myofasciitis capable of rapidly spreading throughout the tissue planes.
Fig. 6. Location of abscess in ano-rectal space. (Vasilevsky CA: Fistula-in-ano and abscess. In Beck DE, Wexner SD [eds]: Fundamentals of Anorectal Surgery, p. 154, 2nd edn. London, WB Saunders, 1998)
Treatment of abscess is always prompt surgical drainage, even of early abscesses that have not developed obvious fluctuance. Antibiotics should be used in adjunct, and not as sole therapy. Superficial abscesses can be drained under local anesthesia. Simple incision and drainage so that the cavity is adequately drained and explored, followed by packed dressing and sitz baths to allow secondary healing, is most commonly performed. A smaller incision with insertion of a catheter drain can also be used. It is important that all loculations and cavities be drained, and that the superficial tissue be kept open until the deeper tissues have healed to prevent a reaccumulation of loculated pus. Deeper abscesses may require counter incisions and placement of a Seton or Penrose drain to keep the tract open. Identified fistulous tracts should be treated with fistulotomy or Seton (discussed below); this is done in the operating room where a more thorough examination can be performed. If the causative crypt or source is identified, excision or definitive treatment should be attempted. After acute treatment of the abscess, the patient should have endoscopy performed if inflammatory bowel disease or malignancy is suspected. Expect approximately 25–50% of abscesses to resolve after initial treatment, with the remaining developing recurrence or fistulas in 1–3 months.15
Anal fistulas are fibrinous tracts of granulation tissue connecting a primary opening within the anal canal to a secondary opening in the perianal skin. The primary opening is most commonly found within the dentate line and usually arises from an infected crypt or abscess. Other causes of fistulas include trauma or surgery, Crohn's disease, fissures, carcinoma, radiation therapy, or chlamydial infections. As the inflamed or infected area drains and granulates, the tract forms and remains patent or persistently draining.
The secondary openings may be single or multiple, and are often the initial sign of an underlying problem. Patients may complain of drainage of pus, blood, stool, and/or mucus. Intermittent pain may be present if the tract becomes occluded and recurring abscesses form. On exam, the external opening is frequently a raised pink papule and may have a palpable cord running subcutaneously toward the anus. Drainage can usually be expressed. The location of the internal opening relative to the secondary opening can be predicted using Goodsall's rule (Fig. 7). Anterior fistulas drain in a radial pattern toward the anus, whereas posterior fistulas drain through a curvilinear tract that enters the anal canal at the posterior midline.
Fig. 7. Goodsall's rule for anal fistula. (Vasilevsky CA: Fistula-in-ano and abscess. In Beck DE, Wexner SD [eds]: Fundamentals of Anorectal Surgery, p. 162, 2nd edn. London, WB Saunders, 1998)
The internal opening usually can be identified during anoscopy. Probing of the internal opening should confirm its passage to the secondary opening, but reverse probing should be performed cautiously to prevent inadvertently creating a false passage. Once the tract is identified, its relationship to the sphincter will determine treatment (Fig. 8). Most commonly, an intersphincteric fistula is found. Transsphincteric fistulas are sequelae of ischiorectal abscesses. Suprasphincteric fistulas originate at the dentate line but course in a cephalad direction above the sphincter mechanism before turning caudally to exit on the perianal or gluteal skin. Extrasphincteric fistulas usually arise from the rectum above the anorectal ring and may be associated with foreign bodies, Crohn's disease, or malignancy. If the tract pathway is not easily determined, proctosigmoidoscopy may help. Barium enema, fistulograms using radiographic contrast material, endoscopic ultrasound, MRI, or CT may also be useful. Colonic, small bowel, and urethral fistulas can occur in an identical fashion, underscoring the importance of identifying an internal opening in the anal canal. Differential diagnosis also includes hidradenitis, pilonidal disease, and infected sebaceous cysts or Bartholin's glands. These entities will not have internal openings in the anal canal.
Fig. 8. Classification of anal fistula: ( A) intersphincteric; ( B) transsphincteric; ( C) suprasphincteric; ( D) extrasphincteric. (Vasilevsky CA: Fistula-in-ano and abscess. In Beck DE, Wexner SD [eds]: Fundamentals of Anorectal Surgery, p. 161, 2nd edn. London, WB Saunders, 1998)
Treatment of fistulas must ensure that healing occurs from the base of the surgical wound to avoid fistula recurrence, while preserving normal sphincter function. Superficial fistulas may be treated by fistulotomy. The tract is exposed, débrided, and left open for the defect to heal secondarily. Marsupialization of the skin edges can be performed to prevent early closure. For higher fistulas that encompass the external sphincter, fistulotomy will cause incontinence; therefore, a staged procedure is performed. Most commonly a Seton drain is placed (Fig. 9). A rubber-band drain or heavy silk suture is placed through the fistula tract and secured, maintaining patency of the tract while promoting fibrosis. At intervals, the Seton is tightened, allowing the deeper portion to heal while maintaining drainage. Gradual fibrotic repair maintains the integrity of the external sphincter. Treatment of large complex fistulas, such as horseshoe abscesses in the supralevator anal space, may require a combination of staged fistulotomies, and Seton or Penrose drains; alternatively, a mucosal advancement flap may be used to close the internal opening.
Newer methods of fistula treatment include using either fibrin glue or a bioprosthetic plug to fill in the fistula tract. Both techniques require the fistula tracts to be first curetted and all local sepsis treated. Fibrin glue is employed after identifying both the external and internal openings, which are then injected with the glue. Bioprosthetic plugs are used in a similar manner. Once both defects have been clearly identifed, the plug is then passed from the internal opening towards the external, with the narrowest portion of the plug snugly fitting at the external opening. The excess material is then trimmed from the anal canal. Both ends of the plug are then further secured into place with suture. Although Johnson et al found recurrence rates to be reduced by utilizing the plug technique, due to the wide spectrum of fistula complexity, recurrence rates for both procedures vary widely, from 13 to 100%.16, 17 The best results have been noted in simple fistulas, which also are the easiest to treat surgically; therefore the role of fibrin glue is controversial.18
Fig. 9. Seton drain for treatment of anal fistula. (Vasilevsky CA: Fistula-in-ano and abscess. In Beck DE, Wexner SD [eds]: Fundamentals of Anorectal Surgery, p. 166, 2nd edn. London, WB Saunders, 1998)
Recurrence of fistulas varies, but approaches 18%,19 and occurs within 2 years in 90% of patients with recurrence.20 Most commonly, recurrence is attributable to misidentification of the primary opening, but can also be attributed to failure to expose the entire fistula tract, and early closure of the superficial tissue. Patients with active inflammatory bowel disease will also have a high recurrence rate.
Patients with rectovaginal fistulas may present with complaints of fecal incontinence or passage of flatus or stool from the vagina, as well as recurrent vaginitis and malodorous or purulent discharge. Most commonly associated with childbirth trauma, rectovaginal fistulas may also develop from Crohn's disease, carcinoma, and radiation therapy. Rarely, pelvic inflammatory disease, diverticulitis, or endometriosis may be implicated as the cause. The fistula openings are most commonly in the distal vagina and anterior dentate line (Fig. 10), but if not easily identified, colovaginal and cystovaginal fistulas must also be considered. Barium studies, fistulograms, MRI, or CT may be necessary to determine the tract course.
Fig. 10. Rectovaginal fistula. (Vasilevsky CA: Fistula-in-ano and abscess. In Beck DE, Wexner SD [eds]: Fundamentals of Anorectal Surgery, p. 163, 2nd edn. London, WB Saunders, 1998)
Repair of the fistula should take into consideration the cause of the fistula, and the presence of acute or active inflammation. Surgery should be delayed until local inflammation and sepsis have resolved.21 Obstetrical fistulas will close spontaneously in up to 50% of patients, lending further support to waiting after the injury has occurred. Superficial anovaginal fistulas may be treated with fistulotomy or reopening of the episiotomy. Layered closures through vaginal or transperineal approaches and endorectal advancement flaps may be necessary to reconstruct the rectovaginal wall and anal sphincter. The procedure chosen is determined by surgeon preference. Fecal diversion via a colostomy is rarely needed for first-time repairs; however, it should be considered if multiple previous attempts have failed. Crohn's disease should be in remission before any surgical intervention, and at times medical management alone can control these rectovaginal fistulas. Surgical treatment should be minimized in Crohn's patients. If the rectum is severely involved with Crohn's, proctectomy and permanent fecal diversion may be the only surgical option. Treatment of malignant fistulas depends on whether the cancer is resectable, and radiation and chemotherapy may be used in conjunction with surgery. Palliative or curative diverting colostomy or bowel resection with colo- or ileo anal pull-through procedures may be required for malignancy- or radiation-related rectovaginal fistulas. Fibrin glue has also been used for rectovaginal fistulas; however, the tract is usually too short to hold the fibrin glue in place and results have varied.
Hidradenitis suppurativa is chronic infection caused by occlusion of the apocrine glands by keratin comedo plugs. Secondary bacterial infection occurs and ruptures deep into the dermis (Fig. 11). Cellulitis, abscess, and chronic draining sinuses develop. There is a familial tendency and an association with cystic acne. Hidradenitis suppurativa usually does not develop until after the onset of puberty, and exacerbations are associated with excessive androgens, pregnancy, the late menstrual cycle, and oral contraceptives. Hidradenitis occurs most commonly in the axilla and inguinal region, and less commonly in the perianal region. The lesions are always distal to the dentate line, thereby distinguishing them from anal fistulas.
Fig. 11. Evaluation of hidradenitis suppurativa: (A) keratin plugging and anal gland rupture; (B) abscess formation; (C) chronic draining sinus. (Rubin RJ, Chinn BT: Perianal hidradenitis suppurative. Surg Clin North Am 74(6):1317, 1994)
Nonsurgical management of perianal hidradenitis includes warm baths or whirlpool, steroids to reduce androgen production, and topical and systemic antibiotics. Common organisms cultured include Streptococcus and Chlamydia spp., but antibiosis should be tailored to cover the anaerobes and gram-negative organisms seen in perianal hidradenitis. Leuprolide used in a long-term daily dose suppresses ovarian and testosterone steroid production and has been successful in suppressing hidradenitis. Also, Accutane, more commonly used in cystic acne, has also shown therapeutic effects with hidradenitis.22
Incision and drainage in the acute setting will relieve symptoms temporarily, but will require further definitive treatment. A more extensive unroofing of the lesions with marsupialization to allow granulation may be adequate for smaller lesions. Limited local excisions have a 20% recurrence rate in the axilla and groin, but a higher success rate with perianal disease. If limited excision has failed, or disease is extensive, than wide en bloc excision should be performed. Healing by secondary intention followed by skin grafting has a high failure rate in the perianal region, which is why local excision is preferred for perianal hidradenitis.
Although pilonidal cysts have historically been thought to be a congenital lesion, the current theory held is that shed hair shafts embed into the skin and then become secondarily infected. Most commonly occurring in men between 16 and 20 years of age, patients present with complaints of pain, tenderness, and drainage from an abscess located in the gluteal fold just below the coccyx. Patients may present with an acute abscess, or a chronic draining pilonidal sinus.
In the acute setting, drainage can be performed with an incision lateral to the midline. For more definitive treatment, an elliptical excision of the sinus tracts should be performed with beveling or marsupialization of the skin edges to prevent early closure. Most surgeons will choose to have the wound granulate, but for sinuses that have been drained and infection controlled preoperatively, primary or Z-plasty closure can be performed.23
Patients with genital condyloma may also have lesions in the perianal region. Patients may complain of pruritus, bleeding, or discharge, or they may be asymptomatic. The human papilloma virus strains are similar to genital condyloma, with subtypes 6 and 11 more commonly forming exophytic lesions, and subtypes 16 and 18 more likely associated with dysplasia and cancer. Condylomas are most commonly transmitted via sexual contact, although anal penetration does not need to occur for perianal condyloma. Transmission can also occur from mother to infant during birth. Differential diagnosis includes squamous cell carcinoma and condyloma lata of secondary syphilis; darkfield microscopy and biopsy are required to differentiate.
Treatment of perianal condyloma is similar to condyloma elsewhere. Podophyllin is a cytotoxin extract from the rhizome of the Podophyllum spp. It can be applied in weekly intervals to the perianal skin lesions, but should not be applied within the anal canal. Bichloracetic acid is also applied in weekly intervals, but it may be applied in the anal canal. 5-FU 5% cream has also been used for condyloma, but causes severe skin irritation, making it less well tolerated.
Several excisional treatment options exist, and each faces the same challenge: adequately removing the infected tissue while sparing minimal loss of unaffected tissue. Direct surgical excision by clipping the lesion at its base can be performed under local anesthesia.
Electrocoagulation and fulguration use heat coagulation to destroy the affected tissue. Care must be taken to avoid deep burns. Carbon dioxide laser ablation can be employed, but again, care to avoid deep burns must be taken. There is also added risk of transmission from aerosolized viral particles, and operating room personnel must wear special masks. Nitrogen oxide, liquid nitrogen or cryoprobes can be used for cryotherapy. All excisional treatments carry a high recurrence rate and multiple treatments are often required.
Several new immunotherapies have been developed. Abcarian developed an autologous vaccine from 5 g of condyloma tissue that was then injected intramuscularly in six weekly doses.24 Eighty-four percent of patients had complete remission, but preparation of the vaccine can be problematic. It is not widely practiced and it has not replaced surgical destruction or excision as the treatment of choice. Interferon-alpha has also been used as a systemic intramuscular injection, injected locally into the lesion, in combination with surgical excision. Results have varied with remission seen in up to 80% of treated groups.25
Infection with the human papilloma virus (HPV) has been implicated in the development of anal intraepithelial neoplasia (AIN) and invasive anal cancer. In this regard, there are parallels between anal and cervical malignancies. Malignant transformation is promoted by a state of immunodeficiency such as that seen with AIDS infection or with immunosuppression following organ transplantation. Just as Pap smears have reduced the mortality from cervical cancer, it is hoped that anal Pap smears for highrisk groups (HPV infection, HIV-positive patients, male homosexuals) will identify patients with high-grade dysplasia and AIN who are at risk for invasive cancer.
Anorectal disorders such as abscesses, fistulas, fissures, and hemorrhoids are common. Women afflicted with these conditions will frequently seek treatment from their gynecologist or internist first, and a basic working knowledge of their management is essential. Distinguishing one condition from another is not always easy because symptoms and physical characteristics overlap. If doubt exists as to the correct diagnosis, referral to a specialist is indicated.
Nelson RL et al: Prevalence of benign anorectal disease in randomly selected populations. Dis Colon Rectum 38: 341, 1995
MacRae HM, MacLeod RS: Comparison of hemorrhoidal treatment modalities. A meta-analysis. Dis Colon Rectum 38: 687, 1995
Endres JC, Steinhagen RM: Lasers in anorectal surgery. Surg Clin North Am 74: 1415, 1994
Randall GM, et al: Prospective randomized comparative study of bipolar versus direct current electrocoagulation for treatment of bleeding internal hemorrhoids. Gastrointest Endosc 40: 403, 1994
Mazier WP: Hemorrhoids, fissures and pruritus ani. Surg Clin North Am 74: 1277, 1994
Hard A. Chan CLH. Cohen CRG: The Surgical Management of Hemorrhoids - A Review. Dig Surg 22:26-33, 2005
Gravié JF, Lehur PA, Huten N, et al: Stapled hemorrhoidopexy versus Milligan-Morgan hemorrhoidectomy: a prospective, randomized, multicenter trial with 2-year postoperative follow up. Ann Surg 2005; 242: 29–35
Sutherland LM, Burchard AK, Matsuda J, et al: A systematic review of stapled hemorrhoidectomy. Arch Surg 2002; 137:1395-1406
Sohn N. Aronoff JS. Cohen FS. Weinstein MA: Transanal hemorrhoidal dearterialization is an alternative to operative hemorrhoidectomy. Am J Surg 182(5): 515-19, 2001
Jiang JK et al: Local thermal stimulation relaxes hypertonic anal sphincter: Evidence of somatoanal reflex. Dis Colon Rectum 42: 1152, 1999
Schouten WR et al: Relationship of anal pressure and anodermal bloodflow: The vascular pathogenesis of anal fissures. Dis Colon Rectum 37: 664, 1994
Altomare DF et al: Glyceryl trinitrate for chronic anal fissure: Healing or headache? Dis Colon Rectum 43: 174, 2000
Maria G et al: Botulinum toxin injections in internal anal sphincter for the treatment of chronic anal fissure: Long-term results after two different dosage regimens. Ann Surg 228: 664, 1998
Pernikoff BJ et al: Reappraisal of partial lateral internal sphincterotomy. Dis Colon Rectum 37: 1291, 1994
Lunniss PJ, Phillips RK: Surgical assessment of acute anorectal sepsis is a better predictor of fistula than microbiological analysis. Br J Surg 81: 368, 1994
Hammond TM, Grahn MF, Lunniss PJ: Fibrin glue in the management of anal fistulae. Colorectal Dis 6(5): 308-319, 2004
Johnson EK. Gaw JU. Armstrong DN: Efficacy of anal fistula plug vs. fibrin glue in closure of anorectal fistulas. Dis Colon Rectum 49(3):371-6, 2006
Abel ME et al: Autologous fibrin glue in the treatment of rectovaginal and complex fistulas. Dis Colon Rectum 36: 447, 1993
Vasilevsky CA: Fistula-in-ano and abscess. In Beck DE, Wexner SD (eds): Fundamentals of Anorectal Surgery. London, WB Saunders, 1998
Rosen L: Anorectal abscess-fistulae. Surg Clin North Am 74: 1293, 1994
Senatore PJ: Anovaginal fistulae. Surg Clin North Am 74: 1361, 1994
Rubin RJ, Chinn BT: Perianal hidradenitis suppurativa. Surg Clin North Am 74: 1317, 1994
Surrell JA: Pilonidal disease. Surg Clin North Am 74: 1309, 1994
Abcarian H, Shawn N: The effectiveness of immunotherapy in the treatment of anal condyloma acumination. J Surg Res 22: 231, 1977
Luchtefeld MA: Perianal condylomata acuminata. Surg Clin North Am 74: 1327, 1994


Here you will find the Commercial Van sales leaders in Canada for September 2018. Each month we compile Commercial Van sales data and reports for North American markets and analyze it to create the best selling list below.
Ford's Transit continued on its sales high in September, with 28.4% more being sold last month than the same month a year ago. That keeps the Transit on track at the end of the third quarter to go 28.5% better than 2017's final total, if it can maintain that momentum through the final three months.
September 2018 saw the GMC Savana's sales growth almost match that f its full size Ford competitor, hitting 27.9% for the month, though year-to-date its overall growth curve is much less steep at 12.% over the past nine months.
Sales of the Mercedes-Benz Metris and Nissan NV200 picked up after a difficult August, though overall small and midsize van sales failed to light up green for September due to a sharp fall for the sales leading in Ford Transit Connect.


text:
Variety Plus Icon Read Next: Adani Group, India's Biggest Corporation, Accused by Hindenburg Research of 'Largest Con' in History
Jan 8, 2018 7:57am PT
Facebook and Sony/ATV Music Publishing Announce Licensing Agreement
By Variety Staff
Variety Staff
@Variety
Variety.com Becomes No. 1 Entertainment Business News Site of 2022 With Record-Breaking Audience Growth 1 week ago
Inside the Critics' Choice Awards: Austin Butler Takes Selfie Requests, Cate Blanchett Loves Michelle Yeoh and Ismael Cruz Córdova and Stephanie Hsu Reunite 2 weeks ago
Variety's 100 Greatest Movies of All Time: How Many Have You Seen? 1 month ago
Courtesy of Facebook
Sony/ATV Music Publishing and Facebook on Monday announced the signing of a licensing agreement.
The multi-territory, multi-year deal is the first between the world's largest publishing company, which oversees a catalog of more than 3 million songs, and Facebook, which has more than 2 billion monthly active users. It provides Sony/ATV's songwriters with a unique opportunity to earn royalties from the use of their music on both Facebook and Instagram.
Late in 2017, Facebook announced a licensing deal with Universal Music Group for its recorded-music and publishing catalogs.
Under the agreement, users will be able to upload and share videos on Facebook, Instagram and Oculus that contain compositions licensed from Sony/ATV's catalog as well as personalize their music experiences with songs from the catalog.
As more and more Facebook users have included music or videos in their posts in recent years, the platform has required users to take down posts using infringing content. Facebook has been in negotiations with music rights holders for many months in an attempt to resolve the situation, and its deals with Universal and Sony/ATV show that it's making progress; sources tell Variety that Warner Music may be the next to announce a deal.
Sony/ATV Chairman and CEO Martin Bandier said: "We are thrilled that in signing this agreement Facebook recognizes the value that music brings to their service and that our songwriters will now benefit from the use of their music on Facebook. We are looking forward to a long and prosperous relationship."
Tamara Hrivnak, Head of Music Business Development and Partnerships, Facebook said: "We're excited to work with the largest music publisher in the world to bring amazing songs which deepen connections between friends and fans. Sony/ATV is a true leader and an absolute champion of writers in the digital space, and we're thrilled to work with them as they grab new opportunities by the horns across all of our platforms."
Sony/ATV Music Publishing

redpajama_set_name: RedPajamaCommonCrawl


text:
in Barcelona, Real Madrid
Options all over: Real Madrid have this advantage over Barcelona in the La Liga race
Kolade Daniel November 26, 2019, 4:30 PM
Squad depth is one of the most important facets of having a football team. Although that importance tends to vary, teams which compete at the very top level of football see squad depth as the foremost requirement in order to stay competitive in the hunt for multiple titles in a single season.
As such, Real Madrid and Barcelona are no different.
Both teams are competing in different competitions with the aim of eventual triumph at the end if the season with the (quality in) squad depth playing a vital role in making sure they reach their goals.
Competition has been particularly fierce this time around with both Spanish giants tied at 28 points in the La Liga and Barcelona only on top due to more goals scored (Skysports).
On The Topic:
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The El Clasico is only a few weeks away and while that could be the first real chance for either side to clearly go top, Real Madrid could have other strong points to capitalize on in the course of the season.
That being said, this season both Barcelona and Real Madrid have been unlucky with injuries to key players at different points of this season.
As per Standard, Real Madrid have been without Marco Asensio, Eden Hazard, Luka Modric, Isco, James Rodriguez, Luka Jovic, Marcelo, Fede Valverde, Brahim Diaz, Rodrygo, Thibaut Courtois, Gareth Bale, Ferland Mendy and Nacho at different points of this season.
Barcelona on the other hand, have lost Lionel Messi, Luis Suarez, Ousmane Dembele, Samuel Umtiti, Jordi Alba, Junior Firpo, Ansu Fati and Neto at one point in time this season.
This has made the start season topsy-turvy for both teams but Real Madid seem to have finally found the balance while Barcelona are still struggling.
Barcelona right now are without Jordi Alba, Clement Lenglet and Nelson Semedo and it is evident the impact those injuries are having and will continue to have especially with Lenglet and Alba.
In their absences, Junior Firpo and Samuel Umtiti fill in those positions. Samuel Umtiti who has played only three league games this season recently returned from a long time out with injury and is yet to be tested in a big game though he has been steady in the last two games.
Junior Firpo has not really convinced many of his abilities. The former Betis man had ginormous shoes to fill and he has barely executed at left back for Barcelona. Valverde did try to play Nelson Semedo and Sergi Roberto at that position but that didn't work out either. Now that Semedo is injured, they are stuck with him for the foreseeable future.
These injuries have also affected them in attack and fortuitously has brought about the emergence of Ansu Fati. Some onlookers will say that some of Barcelona's squad depth comes from the youth team as well but as far as the team is concerned Ansu Fati(who has been injured at some point this season) and Carles Perez is as good as it gets for them.
Real Madrid (as stated previously) have had their injury problems but have weathered the storm due to their strength in depth.
Right now, they are without Marco Asensio, Nacho, James Rodriguez and Lucas Vazquez but have barely felt any of these absences.
They haven't had Asensio at all this season but the presence of Eden Hazard and Vinicius Junior have provided sufficient cover.
Probably their strongest position is in midfield. James Rodriguez had been a regular feature in that position before he got injured but in his absence has seen Federico Valverde come to the fore and do well. They still have Luka Modric, Isco, Toni Kroos, Casemiro and Brahim Diaz in that position.
Where Barcelona make the argument of youngsters, Real can also boast of Rodrygo and Federico Valverde stepping up and making a huge impact with the former keeping Gareth Bale out of the team.
Madrid have cover of at least two players in every position and the competition is fierce. In central defence are where they have the highest advantage over Barcelona.
Real are also lucky to have durable centre-halves in Varane and Ramos but still have Elder Militao in reserve even with Nacho injured compared to Barcelona who have only two recognized central defenders right now.
Already, we have seen Barcelona without Lionel Messi and how vulnerable they can be without their talisman up front and at his age, there is a chance such an injury can occur again. With the business end of the season which includes Champions League knockout games to come, they will be praying that is not the case.
Injuries are an inevitable part of the sport no doubt, but the strength as well as quality in depth is important to fill in the gaps left and Real Madrid on paper and on the pitch have this advantage over Barcelona.
Barcelonareal madrid
Previous article Chelsea's Final piece missing: Lampard has been brilliant but has this issue to address
Next article At all costs: Barcelona and Juventus have this one thing in common
Written by Kolade Daniel
All round lover of the beautiful game... Unbiased analyst and opinion writer.
Chelsea's Final piece missing: Lampard has been brilliant but has this issue to address
At all costs: Barcelona and Juventus have this one thing in common
Manchester United to recall on-loan striker Alexis Sanchez
[Video] Remembering Kobe Bryant's close bond with European football
Man Utd refusing to bulge from €25m valuation of Roma target Chris Smalling
Shock twist in demand means Manchester United could still complete deal for Bruno Fernandes
PSG joins race for Arsenal's Pierre-Emerick Aubameyang
[Video] Could Real Madrid's Isco strengthen Liverpool's attack?
Inter Milan: Details of Christian Eriksen's deal revealed
Lampard rubbishes claims of Chelsea's complete Dembele and Cavani deals
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text:
ACCEPTED

#### According to
Interim Register of Marine and Nonmarine Genera

#### Published in
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#### Original name
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redpajama_set_name: RedPajamaGithub


text:
Sponsor message A whole new perspective on canine OA
A procedure-specific approach to recovery after surgery
What techniques can be used to enhance recovery from surgery?
Medicine Pain management Animal welfare Canine medicine and surgery Feline medicine and surgery Small animal
by Matthew Gurney
Enhanced recovery after surgery (ERAS) has been on the agenda of our medical colleagues since the 1980s when Kehlet et al. first determined that the more pronounced the stress response is in the perioperative period, the longer the recovery from surgery. Recent guidelines typically list 15 to 20 perioperative factors to be considered for enhanced recovery programmes and this article highlights those relevant to veterinary practice.
The stress response is a homeostatic mechanism comprised of hormonal and metabolic changes, which occur in response to anaesthesia and surgery (and anaesthesia without surgery). It is described as an ebb and flow, whereby catabolism occurs to provide substrates for the subsequent recovery; however, this evolutionary survival mechanism is most likely deleterious in a modern surgical context (Desborough et al., 2000).
Minimising the stress response
As an example from human medicine, an optimal ERAS programme for major abdominal surgery (and specific to this surgery) includes minimally invasive surgery (ideally a laparoscopic approach), avoidance of mechanical bowel preparation, avoidance of overloading with fluids before administration of epidural analgesia (or preferably avoidance of epidural analgesia), goal directed fluid therapy, aggressive post-operative nausea, vomiting and pain prophylaxis, limitation of intraoperative and post-operative opioids by using non-opioid analgesics and avoidance of unnecessary drains and catheters (Joshi and Kehlet, 2016). Such elements have been shown to reduce post-operative complications such as ileus, nausea and vomiting, and to encourage early feeding. Early mobilisation is essential.
The questions posed by Kehlet (2017) that we should consider with our patients are:
Why is the patient in the hospital today?
What are the reasons for developing a complication?
Encouraging early discharge is a key area of ERAS. Failure to mobilise following surgery in people is a huge risk factor for thrombotic events and, while we don't tend to see this in our canine and feline patients, there are risks such as hospital-acquired infections to avoid. Of course, we would all rather see our patients returned to the care of their owners as soon as possible.
One of our aims for reducing initiation of the stress response has to be a smooth anaesthetic, where depth of anaesthesia and use of analgesics prevent nociception while at the same time avoiding excessive depth. It is known in humans that even short periods of deep anaesthesia correlate with a greater incidence of post-operative delirium, which is linked to a decline in cognitive function. The alpha-2 agonists fit the bill perfectly here, providing dose-dependent sedation and analgesia, working synergistically with opioids (Grimm et al., 2000). Preliminary studies in dogs indicate a reduction in measured stress hormones with medetomidine premedication compared to acepromazine (Vaisanen, 2002) and clinical experience shows a smoother anaesthetic with either medetomidine or dexmedetomidine premedication.
Using locoregional techniques
The opioid crisis in the USA is driving a change to opioidfree regimens in human post-operative pain management, with increasing evidence that other analgesics are more effective in the immediate post-operative period. Opioids have their place in daily surgical and anaesthetic practice but come with adverse effects. With multimodal techniques, notably preventive local anaesthesia, we can improve patient comfort and reduce our post-operative opioid use.
Bini et al. (2018) compared the effects of methadone 0.3mg/kg either every four hours or according to pain score (prn) in dogs undergoing TPLO surgery, in which a locoregional technique was used. Dogs in the prn group showed improved food intake, less vomiting and less vocalisation compared to the "by the clock" approach to administration.
FIGURE 1 Recovery from sciatic nerve blocks has been compared to other locoregional techniques
Further evidence in support of the huge role of locoregional techniques comes from a study in which dogs undergoing stifle surgery received a femoral and sciatic nerve block (Figure 1), spinal anaesthesia or a fentanyl infusion. Outcome measures included plasma glucose and cortisol measurements to document the stress response and pain scores to guide interventional analgesic requirement (methadone 0.1mg/kg). Analgesia with a peripheral nerve block or spinal anaesthesia prevented the glycaemic and cortisol responses to surgery, promoted better recovery quality and decreased post-operative pain scores compared with fentanyl (Romano et al., 2015).
What must be considered with these two examples is that analgesia must be specific to the procedure. With this knowledge, anaesthetists are beginning to determine optimal analgesic options for common veterinary procedures. It is recognised that nerve blocks for cats undergoing dental extractions result in reduced anaesthetic requirements and improved comfort post-operatively (Aguiar et al., 2014). Further work also recommends long-term analgesia for cats with severe dental disease following extractions (Watanabe et al., 2018), with the aim of enhancing recovery.
Clearly, pain scoring plays a pivotal role in determining patient comfort. Studies in people show that post-operative assessment must include a procedure-specific functional outcome in addition to patient-reported pain scores. The example for the dog undergoing stifle surgery would be the ability to undergo physiotherapy in the 24 hours following surgery with minimal pain. This also highlights the need to move the pet from the kennel to perform the pain scoring.
With optimal perioperative management we can enhance recovery from the stress of anaesthesia and surgery. Focusing on suitable outcome measures for each surgery is necessary to determine the success of our interventions.
Matthew Gurney
Joint Head of Anaesthesia at Anderson Moores
Matthew Gurney, BVSc, CertVA, PgCertVBM, DipECVAA, MRCVS, graduated from the University of Liverpool in 2003. He is a European Veterinary Specialist and an RCVS Recognised Specialist in Veterinary Anaesthesia and Analgesia.
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Now available to pre-order
Targeting pain the way nothing else does, Galliprant is a new, first-in-class piprant. It acts as a prostaglandin receptor antagonist (PRA), specifically blocking the EP4 receptor.
Galliprant tablets contain grapiprant. Legal category POM-V (UK). Further information is available from the Summary of Product Characteristics or datasheet. Information on this veterinary medicinal product is available on the website of the European Medicines Agency http://www.ema.europa.eu/. For further information call Elanco Animal Health on +44 (0)1256 353131 or write to: Elanco Animal Health, Lilly House, Priestley Road, Basingstoke, Hampshire RG24 9NL, United Kingdom. Use medicines responsibly www.noah.co.uk/responsible. Galliprant, Elanco and the diagonal bar logo are trademarks of Elanco or its affiliates. ©2019 Elanco or its affiliates. PM-UK-19-0117
Exercise-induced collapse in dogs
The condition can only be diagnosed by close observation during exercise as animals are otherwise clinically healthy


Oerlikon Group's Second Munich Technology Conference (MTC2) took place this week with industry professionals from all over the world converging to discuss the industrialization of additive manufacturing.
3D Printing Industry returned for the second year to join over 1000 attendees spanning across the two-day conference, a significant increase compared to the estimated 600 attendees of MTC1 last year.
Throughout my time at the MTC2, I recognized recurring factors of concern for a prosperous additive manufacturing industry. This included collaboration and digitization, material development, and advancements in the academic curriculum.
Such themes remained equally emphasized throughout the conference, particularly on the first day of MTC2 during the industrial talk on additive manufacturing and the role of academics, businesses, and government.
"It's not easy to adopt additive, that industrialization is going to take time," said David Joyce, a Vice Chair of GE and President and CEO for GE Aviation.
(Left to right) Moderator Dr. Melinda Crane, Dr. Roland Fischer CEO of Oerlikon Group, David Joyce CEO of GE Aviation, and Jan Mrosik, CEO of the Digital Factory Division at Siemens. Photo by Tia Vialva.
(Left to right) Moderator Dr. Melinda Crane,Dr. Roland Fischer CEO of Oerlikon Group, David Joyce CEO of GE Aviation, and Jan Mrosik, CEO of the Digital Factory Division at Siemens. Photo by Tia Vialva.
Although the factors affecting the industrialization of additive manufacturing differ in importance from the industry experts, it is evident from my time at the MTC2 that the goal of 3D printing reaching a broader market remains the same.
Subscribe to the 3D Printing Industry newsletter, like us Facebook and follow us on Twitter to stay up to date with all the latest additive manufacturing news and insight.
Featured image shows the exterior of the Second Munich Technology Conference. Photo by Tia Vialva.


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Sophsterlicious • UK Blog: FOTD - Body Shop Browns.
I never really stick with doing make up looks on my blog but I decided I yesterday that I would try and change that.
So I got out a few things yesterday and did a brown/bronze kinda look. I used the Body Shop Eye Trio in 02 - Sundown Glow It has three gorgeous shades in it. I also used a body shop kohl pencil as a base in the colour burnised amber (I think?) .. Oh, and I used Collosal Lash mascara.
@ Dressjunkie - The kohl pencil I used as a base is slightly metallicy, and the eyeshadow is a shimmer/metallic finish too.
Great quality photos. I wish I could get better quality ones, but my camera just isn't good enough.
That said as long as the end result is true life, I guess it doesn't matter too much.


text:
ENGINEERING NOTEBOOK: LEARNING RUSTS WITH TOO MANY LINKED LISTS!
February 03, 2018 Reading time: 4 minutes engineering notebook
I've been reading about implementing advanced collections in Rust thanks to Alexis Beingessner's wonderful, if perhaps excessively opinionated, lecture on "exceptional" collections1. Rust's enforced memory correctness requires the programmer to make intelligent decisions about references and move semantics, stuff no one's ever really had to think about in C or C++. I'm having a hard time internalizing this stuff, so here's my stab at recording what I've learned. His first structure is the singly linked list.
In Lisp, a list is just a data structure, often called a CONS, with two slots, the CAR and the CDR. The CAR slot holds your data. The CDR slot holds a pointer to the next CONS, or NIL, which means "The end of the List." A CONS that is only NIL is the empty list.
In Rust, you have to be concerned with both the heap and the stack. So, in Rust, you need a data structure to point to the head of the list, a sum-type to differentiate between the NIL case and the CONS case, and a CONS structure to hold the CAR and the CDR in the non-NIL case. The head can go on the stack; the list can be on the heap after that.
In fact, the head has to go onto the heap, because otherwise your list has a recursive structure, and Rust doesn't know how to size it. By using a Box, which is a handle to a heap object, you tell Rust the CDR is the size of a pointer, now Rust knows how to size and allocate it.
When doing a cons, there's a moment when you create the new node, attach existing list to it, then retuns the new node as the head. Because we have a separate object to manage pointing to the head, that's a two-step operation. Rust objects: at some point, the head object exists in two places, and Rust doesn't like that. To overcome that, Beingessner uses the mem::replace function to make sure that the head temporarily has an acceptable NIL value when building the new node, so that the head object can then be made to point to the new node later.
Popping them off the list (Beingessner is more building a stack here at the moment) has a similar problem, and a similar solution: so that we can work with the recently-popped node, we have set the head to NIL temporarily, then fix it once we've extracted the data. But because they're boxed, we need to move the node to the stack (and yes, this apparently results in a bitmap copy!) so that we have a local copy we can work with.
The last thing Beingessner shows us is the Drop trait. Normally, this wouldn't be an issue; Rust is very good about cleaning up after itself, and this stack would clean up after itself when the head goes completely out of scope. But, Beingessner writes, that clean-up would be recursive. Since our list is on the heap2, it can grow to occupy all the memory available, which is fine. But the stack does have an upper limit, and a recursive function would blow the stack, especially since in this case there's a follow-on operation that can't be tail-call optimized: we need to drop the contents inside the Box first, then drop the Box. (Rust currently doesn't do tail-call optimization anyway.) Beingessner teaches how to write this function manually and iteratively so that the default recursive version doesn't blow you up.
So those are the things I've learned so far: how to read debugging output from the borrower, how to handle the stack and the heap, how to manage temporary objects to keep the borrower happy in multi-step memory management code, how to unbox items to get at their insides, and how to re-write recursive Drop functions to make them iterative and efficient.
1 Beingessner apparently believes the only thing you need aside from the traditional scalars is arrays and dictionaries; trees, graphs, tries, lists, stacks, queues, priority heaps are all unusual and unneeded by most programmers. He's not wrong about that: 99% of my professional life I've never needed anything more advanced than a dictionary. But right now, I do need these weird things.
2 I avoided writing "... since our stack is on the heap," because that would just be confusing.


text:
Q: What is the probability that the number chosen will have '0' as at least one digit? An integer from $100$ through $999$ inclusive is to be chosen at random. What is the probability that the number chosen will have $0$ as at least one digit?
Here is a list of answers

A: There are $999-99=900$ numbers in the range from $100$ to $999$ inclusive. The number of three-digit numbers using only digits $1$ through $9$ inclusive is $9\times9\times9=729.$ Thus the probability that a random three-digit number has no zeroes in its decimal representation is
$$\frac{9\times9\times9}{900}=\frac{9\times9}{100}=81\%$$
and so the probability that it has at least one zero is
$$100\%-81\%=19\%$$
which is the same as
$$\frac{171}{900}=\frac{19}{100}=19\%.$$

A: There are $90=10\times9$ numbers which have a 0 as the last digit, i.e. of the form _ _ $0$.
There are $90=10\times9$ numbers which have a 0 as the second digit, i.e. of the form _ $0$ _.
However in counting these those with a $0$ as both second and last digit have been counted twice. There are 9 numbers which have a $0$ as both second and last digit, i.e. of the form _ $0$ $0$. These $9$ must be subtracted off as they have been counted twice.
So the answer is $90+90-9=171$.

A: You can generate your number by independently picking the first digit uniformly from $\{1,\ldots,9\}$ and picking the second and third digits uniformly from $\{0,\ldots,9\}$. The first digit will not be a zero. Let $A$ be the event that the second digit is zero, and $B$ the event that the third digit is zero. You want $P(A\cup B)$ which equals $P(A)+P(B)-P(A\cap B)$. Argue that $P(A)=P(B)=\frac1{10}$ and $P(A\cap B)=\frac1{100}$, so the answer is $\frac1{10}+\frac1{10}-\frac1{100}=\frac{19}{100}$.

redpajama_set_name: RedPajamaStackExchange


Renegade-Studios.com simply provides yall a gallery of Outer Space Lamp. The writing of Delightful Outer Space Lamp Review was released by Markus Schön on February, 17 2016.
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text:
require 'net/http'
require 'tempfile'
require 'uri'

class GoogleTts::Phrase
  URL_HOST = "translate.google.com"
  URL_PATH = lambda { |text, lang| "/translate_tts?ie=UTF-8&q=#{URI.escape(text)}&tl=#{lang}" }

  attr_reader :lang
  attr_reader :text

  def initialize(text, lang = :en, options = {})
    @text = text
    @lang = lang
    @tempfile_is_downloaded = false
    if options[:proxy].present?
      @proxy = OpenStruct.new(options[:proxy])
    end
  end

  def file
    @file ||= Tempfile.new "tts_#{rand(10**9)}.mpeg"
    return @file if @downloaded

    save_to_file(@file)
  end

  def save_to_file(file)
    connection = Net::HTTP
    connection = Net::HTTP::Proxy(@proxy.ip, @proxy.port) if @proxy.present?

    connection.start(URL_HOST) do |http|
      open(file.path, "wb") do |f|
        chopped_text.each do |part|
          response = http.get(URL_PATH.call(part, lang.to_s))
          if response.code.to_i != 200
            raise Exception.new("Probably forbiden access. Got response with code '#{response.code}'")
          end
          f.write(response.body)
        end
      end
    end
    @tempfile_is_downloaded ||= file == @file

    file
  end

  private

  def chopped_text
    return @chopped_text if @chopped_text.present?

    @chopped_text = []
    formated_text = @text.squeeze(".").gsub(/[\n\r]/, " ").squeeze(" ")

    formated_text.split(".").each do |sentence|
      if sentence.length <= 100
        @chopped_text << "#{sentence}."
        next
      end

      @chopped_text << "" if @chopped_text.last != ""
      sentence.split(" ").each do |word|
        next if word.length > 100 # if word is longer than 100 symbols, probably it's nonsence

        if (@chopped_text.last + word).length > 100
          @chopped_text += [word] # add word as new part
        else
          @chopped_text.last += word
        end
      end
    end

    @chopped_text
  end
end


text:
Aaron Swartz.(Photo by: Wikimedia Commons)
Internet prodigy Aaron Swartz commits suicide at 26
Swartz worked to fight the Stop Online Piracy Act in Congress, was an early member of the team that built Reddit.
Internet activist and computer prodigy Aaron Swartz, who helped create an early version of the Web feed system RSS and was facing federal criminal charges in a controversial fraud case, has committed suicide at age 26, authorities said on Saturday.
Police found Swartz's body in his apartment in the New York City borough of Brooklyn on Friday, according to a spokeswoman for the city's chief medical examiner, which ruled the death a suicide by hanging.
Swartz is widely credited with being a co-author of the specifications for the Web feed format RSS 1.0, which he worked on at age 14, according to a blog post on Saturday from his friend, science fiction author Cory Doctorow.
RSS, which stands for Rich Site Summary, is a format for delivering to users content from sites that change constantly, such as news pages and blogs.
Over the years, he became an online icon for helping to make a virtual mountain of information freely available to the public, including an estimated 19 million pages of federal court documents from the PACER case-law system.
"Information is power. But like all power, there are those who want to keep it for themselves," Swartz wrote in an online "manifesto" dated 2008.
"The world's entire scientific and cultural heritage, published over centuries in books and journals, is increasingly being digitized and locked up by a handful of private corporations. ... sharing isn't immoral - it's a moral imperative. Only those blinded by greed would refuse to let a friend make a copy," he wrote.
That belief - that information should be shared and available for the good of society - prompted Swartz to found the nonprofit group DemandProgress.
The group led a successful campaign to block a bill introduced in 2011 in the US House of Representatives called the Stop Online Piracy Act.
The bill, which was withdrawn amid public pressure, would have allowed court orders to curb access to certain websites deemed to be engaging in illegal sharing of intellectual property.
Swartz and other activists objected on the grounds it would give the government too many broad powers to censor and squelch legitimate Web communication.
But Swartz faced trouble in July 2011, when he was indicted by a federal grand jury of wire fraud, computer fraud and other charges related to allegedly stealing millions of academic articles and journals from a digital archive at the Massachusetts Institute of Technology.
According to the federal indictment, Swartz - who was a fellow at Harvard University's Edmond J. Safra Center for Ethics - used MIT's computer networks to steal more than 4 million articles from JSTOR, an online archive and journal distribution service.
JSTOR did not press charges against Swartz after the digitized copies of the articles were returned, according to media reports at the time.
Swartz, who pleaded not guilty to all counts, faced 35 years in prison and a $1 million fine if convicted. He was released on bond. His trial was scheduled to start later this year.
'Harsh array of charges'
In a statement released Saturday, the family and partner of Swartz praised his "brilliance" and "profound" commitment to social justice, and struck out at what they said were decisions made at MIT and by prosecutors that contributed to his death.
"Aaron's death is not simply a personal tragedy. It is the product of a criminal justice system rife with intimidation and prosecutorial overreach," the statement said.
"The US Attorney's office pursued an exceptionally harsh array of charges, carrying potentially over 30 years in prison, to punish an alleged crime that had no victims," it added.
A spokeswoman for the US Attorney's office said they wanted to respect the family's privacy and did "not feel it is appropriate to comment on the case at this time." MIT could not be reached for comment
Swartz's funeral is scheduled for Tuesday in Highland Park, Illinois. On Saturday, online tributes to Swartz flooded across cyberspace.
"Aaron had an unbeatable combination of political insight, technical skill and intelligence about people and issues," Doctorow, co-editor of the weblog Boing Boing, wrote on the site.
Doctorow wrote that Swartz had "problems with depression for many years."
Swartz also played a role in building the news-sharing website Reddit, but left the company after it was acquired by Wired magazine owner Conde Nast. Recalling that time of his life, Swartz described his struggles with dark feelings.
In an online account of his life and work, Swartz said he became "miserable" after going to work at the San Francisco offices of Wired after Reddit was acquired.
"I took a long Christmas vacation," he wrote. "I got sick. I thought of suicide. I ran from the police. And when I got back on Monday morning, I was asked to resign."
Tim Berners-Lee, who is credited as the most important figure in the creation of the World Wide Web, commemorated Swartz in a Twitter post on Saturday.
"Aaron dead," he wrote. "World wanderers, we have lost a wise elder. Hackers for right, we are one down. Parents all, we have lost a child. Let us weep."


text:
MONEY INTO LIGHT
FILM INTERVIEWS, ESSAYS AND ARTICLES BY PAUL ROWLANDS
AN INTERVIEW WITH LARRY COHEN (PART 1 OF 3)
Larry Cohen is the subject of the brilliant new documentary by Steve Mitchell - KING COHEN: THE WILD WORLD OF FILMMAKER LARRY COHEN. A true independent and maverick, Cohen got his start in television creating the Western series Branded (1965-66) and the sci-fi series The Invaders (1967-8), and writing episodes of series such as The Fugitive and The Defenders. Making his feature directing debut with the dark comedy BONE (1972), Cohen established himself as a filmmaker able to craft wildly entertaining, challenging, socially satirical films on tight budgets, in an array of genres. His incredible filmography, which has inspired other filmmakers like Martin Scorsese, J.J. Abrams, John Landis and Joe Dante (all of whom are interviewed in KING COHEN), includes the blaxploitation gangster pic BLACK CAESAR (1973), the monster movie/ drama IT'S ALIVE (1974) and its two sequels, the extraordinary GOD TOLD ME TO (1976), the historical drama THE PRIVATE FILES OF J. EDGAR HOOVER (1977), the monster movie/ heist thriller/ drama Q - THE WINGED SERPENT (1982), the satirical horror film THE STUFF (1985), the horror comedy THE AMBULANCE (1990), and the screenplays for PHONE BOOTH (2002), BEST SELLER (1987), GUILTY AS SIN (1993), BODY SNATCHERS (1993), CELLULAR (2004) and MANIAC COP (1988). In the first part of a three-part interview I spoke with Cohen about why he loves filmmaking, his approaches towards his craft, and how he measures the success of each film.
What do you love the most about filmmaking?
In my particular case it was the freedom. I got to write, produce, direct and edit, and be in control of all of my 20 movies from start to finish, which was a unique experience. Most directors have supervision from studio executives, producers and investors, and a lot of interference, so half of their time is spent arguing with these people and trying to convince them of things. I never had to do that. Whatever I wanted to do was allowed without any committee interference. I just made my movie and changed whatever I wanted to. I sometimes wrote new scenes or created new characters.
On the set of IT'S ALIVE.
How do you measure the success of a film you have made?
It's just whether I am personally happy with it. I make films to please myself. I do like to go to the theater and see audiences responding to my films in person. I hear of these filmmakers who say once they finish a film they never see it again ever. I don't believe it. I just got back from Manhattan, where they ran seven of my movies, and we sold out every show. I got to do a Q and A, and I enjoyed seeing the pictures again after all these years, particularly as the prints held up very well.
Which accolades have made you the happiest over your career?
I've received plenty of different awards from different places. I have a whole shelf full of them, but they really don't mean anything to me. Even an Oscar wouldn't mean anything to me because I know the history of the industry. I've had many Oscar winners work on my movies who were happy to get the job. Having an Oscar doesn't always mean that you are going to have continued success or affluence. One person wins it one year, another the next year, and so on, and no-one remembers particularly.
You have proved adept at many different genres. How do you feel about the balance of the genres you have worked in over your career? Would you have liked to have made more films in different genres, like comedy for example?
I didn't have too much success with comedies. There was a lot of comedy and comedic sections and comedic characters in my 'straight' movies but the films that I did that were pure comedy never fared as well, although I did enjoy making them because of the people that were in them. I'm best known for thrillers with a high degree of comedy in them.
You once said that had your first film BONE been more of a success, you might have had more of a career as a more esoteric director. Do you have any regrets that your career didn't go that way?
If BONE had become a success, I would have become a studio director of high-budget films, and I never would have had the same degree of freedom that I have had, and I probably would not have known what I was missing. On the few experiences where I have written screenplays that were produced and directed by other people, there were so many petty arguments and disagreements between people, and jockeying for importance amongst the staff, that it was just miserable for the director of the picture. They weren't the pure experiences I was used to making my own films. There aren't too many of us that have that prerogative of making films how we want to make them. You usually have to be either very successful or able to make movies at a lower budget. If you're anywhere in the middle you're just subject to constant irritation by people butting in all the time and trying to tell you what to do. I wouldn't have been able to make movies like that. I got spoiled early on, and after that I could only do my own thing.
Directing THE AMBULANCE.
You have a distinct interest in taking things we consider as benign and making them malignant. Where did this interest come from?
I don't know where it came from. Every human being has their different outlook on life. I always saw a great deal of dark humor in serious events, and that is what I put on the screen. Taking a baby and making a monster out of it (IT'S ALIVE). Taking ice cream and making a monster out of it (THE STUFF). Taking an ambulance and making a monster out of it (THE AMBULANCE). There's certainly a tradition that I have followed in each of my movies.
You are also excellent at twisting preconceptions and bringing together different tones and genres in a single film. What is the key to pulling this off?
Claude Chabrol, the great French filmmaker, was a fan of my movies and kept asking me ''How do you do that? How do you get the comedy into the drama without affecting the dramatic elements and ruining the suspense?'' I suppose it's just a style I have and something I'm able to do, like some other novelists or filmmakers. The characters that I create are solid characters. They're not foolish or frivolous. They're not in there just to make a joke and look stupid. They have a reason for being and a logical progression of character. If they do something funny in the process, it doesn't destroy the reality of the situation. There are some filmmakers who make attempts to do all this and it just comes off as silly.
Your films are never ever boring. Do you often think about the attention span of the viewer? Do you use yourself as a gauge?
Yes, I do. I like movies that move along and I find that almost every movie that I see these days is too long. Now that some directors get final cut, they don't want to lose anything, and sometimes you have the same scene played two or three times. Then, when the film comes out on DVD and Blu-ray they put in all the other scenes that they took out, and you have to sit through another half hour of the movie. My movies are always around 90 to 100 minutes and that's it.
You manage to make New York look and feel different than other filmmakers. You also seem to always find locations that haven't been used before.
I love New York. It's a great backlot. Everywhere you go, there's something interesting. It has an interesting texture. There are a lot of old and decrepit buildings. Modern buildings. Skyscrapers. Glass buildings, silver buildings, gold buildings. It's a wonderland, and I like to capture it on film. It's great because you don't have to deal with the expense of building sets. It's all there. You just have to find the right places. For Q - THE WINGED SERPENT, the Chrysler Building was absolutely perfect. We couldn't afford to build any parts of the building, so we had to shoot in the real turrets of the Chrysler Building, 88 storeys above the street. We were up there on little ladders, perched with cables, trying to keep from falling off the building as we shot the movie. It was dangerous, but I went up there and the crew followed me and we got the scenes and made a very good picture I think. Most people would have built that building in a set somewhere, but it wouldn't have been the same.
On the set of BLACK CAESAR.
Is it a conscious decision to cast actors who don't look like movie stars and look like people you'd meet on the street?
I just try to cast actors who are going to be believable in the parts. I've shot so many movies in New York, and there are so many good actors there who have theater experience and are dying to be in the movies. Back when I started directing movies, nobody was making movies in New York. Now a lot of film and TV is shot there because of the tax benefits, which we never had. In fact shooting in New York was difficult to put together because the union requirements were so heavy and it was so much more expensive to shoot there than in California. I didn't care because my movies never cost so much money and I always knew how to control the budget.
Your films have a very loose, exciting, in the moment energy. Do you keep a very energetic set when you are filming?
Oh yeah, absolutely. We shoot very long hours. I am sure that people who have worked for me over the years thought I was on some sort of drug because I never got tired and I was always so full of pep and energy. We'd be coming up to 13 or 14 hours and I would be tap dancing around and telling jokes and trying to keep everybody entertained so they didn't get too exhausted. Everybody always complained that I worked them such long hours but when I announced my next movie the same people would be back wanting to work with me again. So they obviously enjoyed the experience, even though I was a slave driver!
Do you think you're at your happiest when you're on a set?
Oh, there's no question. There's nothing to equal it. On most other movies, particularly big movies, the actors come in and they're the stars of the movie. Everyone is catering to them, and in fear of them. The stars don't want to be spoken to by the crew. They don't want people to look at them. They have all kinds of demands that are just nonsense. On my pictures, it doesn't matter who the actors are, I'm the star of the movie! They're all gravitating around me and want to see what I'm doing next. The actors forget about being the stars and they just get into their parts. Even on the days they're not scheduled to work, actors often show up to set just to see what is happening. That's a huge compliment to me.
Do you write every day?
Yes, I do, even if it's just a couple of scenes or a couple of notes. I'm constantly coming up with new ideas. More than I could possibly turn into scripts.
What usually kickstarts a script?
I just get an idea for a story and I feel like I want to make it as a movie. That compels me to write the script. I don't write outlines. I just start writing a story and the dialogue. I usually start somewhere in the middle. I write an interesting scene that has a lot of juice, something that gets me hooked up into the whole movie – a scene where the characters start coming together and interacting with each other. On the first day we start shooting the picture I like to shoot a scene like that to help get the actors hooked into their parts right away, the same way I got hooked originally into the story. Often I give the actors some money and say ''Go and buy your own costumes. '' It helps personalise the parts for them. I give the actors a lot of responsibility.
Part two of the interview.
KING COHEN will be released in cinemas and on VOD later in the year, and will be screened at Fright Fest in London on August 25 and at the Sitges International Film Festival in October.
Larry's website.
The KING COHEN website.
Interview by Paul Rowlands. Copyright © Paul Rowlands, 2017. All rights reserved.
Posted by Paul Rowlands
Labels: Interview: LARRY COHEN (PART 1 OF 3)
About MONEY INTO LIGHT and PAUL ROWLANDS
MONEY INTO LIGHT was founded in 2011. This site is a celebration of all things cinema. Here you will find interviews with actors and actresses, directors, screenwriters, producers, and many people connected to film who have fascinating stories to tell about their lives and careers. There are also essays and reviews of classic, current and overlooked films in which we try to look at films from a unique or personal perspective. It's my aim that Money Into Light (the name of the site is derived from John Boorman's published diary of filming 1985's THE EMERALD FOREST) at the very least adds some new information and perspectives as regards an art form I have loved since I was a child. Please enjoy your visit. You can find find MIL on Facebook, where any enquiries can be sent. Please 'like' the page to ensure updates.
PAUL ROWLANDS was born near Chester in the UK, but currently resides in Japan. He has been in love with movies, and with writing about them, from an early age. His work has appeared in the James Bond magazine Kiss Kiss Bang Bang and on Indiewire, and he is the author of several unpublished novels, short stories and screenplays.
AN INTERVIEW WITH CRAIG McKAY (PART 2 OF 2)
LUPITA PECKINPAH TALKS ABOUT HER FATHER, SAM PECKINPAH
DANIEL WATERS ON 'BATMAN RETURNS'
DANIEL WATERS ON 'HEATHERS' (PART 2 OF 2)
DANIEL WATERS ON 'HUDSON HAWK'
AN INTERVIEW WITH PETER HYAMS (PART 1 OF 2)
PAUL ROWLANDS INTERVIEWS NORMAN WANSTALL PART II
WALTER HILL ON 'THE COWBOY ILIAD' (PART 1 OF 3)
PATTI D'ARBANVILLE TALKS TO PAUL ROWLANDS
MICHAEL LEHMANN ON 'HEATHERS' (PART 1 OF 2)
Article: 'EXORCIST' LEGACY (PART 2)
Article: THE MAKING OF QUANTUM OF SOLACE
BOOK REVIEW: Some Kind of Hero by Matthew Field and Ajay Chowdhury
Essay: LOVE SEX AND DEATH (EYES WIDE SHUT)
Essay: MULHOLLAND DRIVE
Essay: QUANTUM OF SOLACE
Interview: ALBERT PYUN (PART 1 OF 2)
Interview: ALEX COX on SID AND NANCY
Interview: ALEX PROYAS (PART 1 OF 3)
Interview: ALEXANDER NEVSKY ON 'BLACK ROSE'
Interview: ANDREAS WISNIEWSKI
Interview: ANNE WINTERS on 'MOM AND DAD'
Interview: ANSEL FARAJ ON 'DOCTOR MABUSE'
Interview: BARRY HUNT on 'ANSE AND BHULE' (PART 1 OF 2)
Interview: BARRY NEWMAN (PART 1 OF 3)
Interview: BARRY WARD ON 'REALIVE'
Interview: BRAHIM ACHABBAKHE
Interview: BRENDAN MULDOWNEY ON 'PILGRIMAGE' (PART 1 OF 2)
Interview: BRIAN JAMIESON (PART 1 OF 3)
Interview: C.M. TALKINGTON (PART 1 OF 3)
Interview: CANDY CLARK on AMERICAN GRAFFITI
Interview: CANDY CLARK on FAT CITY
Interview: CANDY CLARK on THE MAN WHO FELL TO EARTH
Interview: CARL GOTTLIEB ON 'JAWS'
Interview: CHRISTA FULLER ON SAM FULLER
Interview: COLIN VAINES (PART 1 OF 2)
Interview: CRAIG McKAY (PART 1 OF 2)
Interview: DAMIEN POWER on KILLING GROUND'
Interview: DAN PETRIE JR ON BEVERLY HILLS COP
Interview: DAN PETRIE JR ON THE BIG EASY
Interview: DANIEL KREMER ON 'OVERWHELM THE SKY' (PART 1 OF 3)
Interview: DANIEL KREMER on SIDNEY J. FURIE (PART 1 OF 2)
Interview: DANIEL WATERS on 'BATMAN RETURNS'
Interview: DANIEL WATERS on 'HEATHERS' (PART 1 OF 2)
Interview: DANIEL WATERS ON 'HUDSON HAWK'
Interview: DARRYL PONICSAN (PART 1 OF 3)
Interview: DEREK WAYNE JOHNSON ON 'JOHN G. AVILDSEN: KING OF THE UNDERDOGS' (PART 1 OF 2)
Interview: DOMINICK STARCK ON 'THE HITMAN AGENCY' (PART 1 OF 2)
Interview: DOMINIK STARCK ON 'THE HITMAN AGENCY' (PART 2 OF 2)
Interview: DON 'THE DRAGON' WILSON (PART 1 OF 2)
Interview: DREW STONE ON 'WHO THE F**CK IS THAT GUY?'
Interview: DWAYNE EPSTEIN on LEE MARVIN
Interview: E.B. HUGHES
Interview: E.B. HUGHES ON 'TURNABOUT'
Interview: ED NEUMEIER ON ROBOCOP
Interview: FRED WILLIAMSON
Interview: GARY POWELL
Interview: GARY YOUNG on 'HARRY BROWN'
Interview: GEORGE ARMITAGE (PART 1 OF 3)
Interview: GEORGE MALKO (PART 1 OF 2)
Interview: GREG TRAVIS (1 OF 2)
Interview: HARRY MOK
Interview: HOWARD ROSENMAN (PART 1 OF 2)
Interview: JACK HILL (PART 1 OF 2)
Interview: JAIME FALERO
Interview: JAMES GRAY
Interview: JEFFREY ALAN FISKIN (PART 1 OF 3)
Interview: JIM HELTON (PART 1 OF 3)
Interview: JINO KANG
Interview: JL SOSA
Interview: JOHN ALTMAN
Interview: JOHN CORK (PART 1)
Interview: JOHN FASANO on ALIEN 3
Interview: JOHN McNAUGHTON (PART 1 OF 3)
Interview: JONATHAN TAPLIN on MEAN STREETS
Interview: JONATHAN WEISSLER
Interview: JUDITH RASCOE ON 'WHO'LL STOP THE RAIN'
Interview: KEVIN ALLEN ON 'TWIN TOWN'
Interview: KRISTANNA LOKEN ON 'BLACK ROSE'
Interview: LANA WOOD
Interview: LARRY COHEN (PART 1 OF 3)
Interview: LARRY KARASZEWSKI on 'ED WOOD' (PART 1 OF 2)
Interview: LARRY KARASZEWSKI ON 'LARRY FLYNT'
Interview: LARRY KARASZEWSKI ON 'LARRY FLYNT' (1 OF 2)
Interview: LARRY KARASZEWSKI on ED WOOD' (PART 2 OF 2)
Interview: LARRY KARASZEWSKI/ SCOTT ALEXANDER on BIG EYES
Interview: LAWRENCE BLOCK
Interview: LEA THOMPSON (PART 1 OF 3)
Interview: LENNY ABRAHAMSON
Interview: LUPITA PECKINPAH ON SAM PECKINPAH
Interview: MARK CHRISTOPHER ON '54'
Interview: MARK O'CONNELL ON HIS FAVE UNDERRATED BONDS
Interview: MARK O'CONNELL ON THE MOST UNDERRATED SPIELBERG FILMS
Interview: MARK PELLINGTON (PART 1 OF 2)
Interview: MARK PELLINGTON on 'NOSTALGIA'
Interview: MARK PROTOSEVICH (1 OF 2)
Interview: MARTHA PINSON (1 OF 2)
Interview: MARTIN SAMUEL
Interview: MATTHEW WILDER ON 'DOG EAT DOG'
Interview: MATTHEW WILDER ON 'YOUR NAME HERE'
Interview: MICHAEL DEELEY (PART 1 OF 2)
Interview: MICHAEL GERBOSI ON WRITING 'AUTO FOCUS' (PART 1 OF 2)
Interview: MICHAEL LEHMANN ON 'HEATHERS' (PART 1 OF 2)
Interview: MICHAEL MORIARTY (1 OF 2)
Interview: MICHAEL TOLKIN
Interview: MICK AUDSLEY (PART 1 OF 2)
Interview: MIKE HODGES (PART 1 OF 2)
Interview: MONTE HELLMAN
Interview: MONTE HELLMAN ON HIS FAVE OVERLOOKED FILMS
Interview: NANCY ALLEN (PART 1 OF 2)
Interview: NANCY BUIRSKI ON 'BY SIDNEY LUMET'
Interview: NEIL JONES ON 'THE REVEREND'
Interview: NICK REDMAN (1 OF 2)
Interview: NORMAN WANSTALL PART 1
Interview: PATTI D'ARBANVILLE
Interview: PAUL MAHER JR ON TERRENCE MALICK
Interview: PETER BISKIND ON 'EASY RIDERS RAGING BULLS'
Interview: PETER CRAIG (PART 1 OF 2)
Interview: PETER HYAMS (PART 1 OF 2)
Interview: PHIL JOANOU (1 OF 4)
Interview: PHIL JOANOU (PART 2 OF 4)
Interview: REED MORANO
Interview: RIC MENELLO ON JAMES GRAY
Interview: RICHARD LEMAY ON 'DEMENTIA 13'
Interview: RICHARD RUSH (PART 1 OF 4)
Interview: RICHARD SHEPARD (PART 1 OF 3)
Interview: RICHARD SHEPARD on 'TOKYO PROJECT' (PART 1 0F 3)
Interview: RICHARD SHEPARD on 'TOKYO PROJECT' (PART 2 OF 3)
Interview: RICHARD STANLEY on DUST DEVIL
Interview: ROBERT SELLERS on OLIVER REED
Interview: ROBIN HARDY on THE WICKER MAN
Interview: ROD LURIE on STRAW DOGS
Interview: RUSSELL MULCAHY (PART 1 OF 2)
Interview: SALLY KIRKLAND
Interview: SAM FIRSTENBERG (PART 1 OF 2)
Interview: SCOTT BRADLEY ON HIS FAVE OVERLOOKED FILMS
Interview: SEAN ELLIS (PART 1 OF 2)
Interview: SEAN STONE
Interview: SETH SWIRSKY ON 'BEATLES STORIES'
Interview: SIDNEY J. FURIE (PART 1 OF 2)
Interview: SIEGEL/ McGEHEE (PART 1 OF 2)
Interview: SILVIO SAMAC
Interview: SIMON RUMLEY (PART 1 OF 2)
Interview: SIMON WEST on 'STRATTON'
Interview: STEPHEN VAN VUUREN ON 'IN SATURN'S RINGS' (PART 1 OF 2)
Interview: STEVE DE JARNATT (1 of 3)
INTERVIEW: STEVEN LAMBERT
Interview: STEVEN-CHARLES JAFFE
Interview: STUART BRENNAN
Interview: STUART GALBRAITH IV ON HIS FAVE OVERLOOKED MOVIES
Interview: TED KOTCHEFF (PART 1 OF 2)
Interview: TERRY BAMBER (PART 1)
Interview: TERRY McMAHON on 'CHARLIE CASANOVA'
Interview: TERRY McMAHON ON 'PATRICK'S DAY'
Interview: TOM DICILLO
Interview: TONY GRISONI
Interview: TONY KLINGER on MICHAEL KLINGER PART 1
Interview: WALTER HILL ON 'THE COWBOY ILIAD' (PART 2 OF 3)
Interview: WAYNE KRAMER (PART 1 of 3)
Interview:BARRY NEWMAN (PART 2 OF 3)
Review: A FULLER LIFE
Review: AGE OF KILL
Review: BLUE VALENTINE
Review: BREWSTER MCCLOUD
Review: CANDY
Review: COCKFIGHTER
Review: EXORCIST II - THE HERETIC
Review: FISHING WITH JOHN
Review: FRUITVALE STATION
Review: GAHAN WILSON - BORN DEAD STILL WEIRD
Review: GATTACA
Review: GRAVITY
Review: HAROLD AND MAUDE
Review: MIDLIFE
Review: NIGHT MOVES (1975)
Review: PACING THE CAGE
Review: PHANTOM OF THE PARADISE
Review: SKYFALL
Review: SORCERER
Review: SPECTRE
Review: SPECTRE (JAPANESE)
Review: THE BRAVE
Review: THE DRIVER
Review: THE DUELLISTS
Review: THE GAMBLER (1974)
Review: THE OLIVER STONE EXPERIENCE (BOOK)
Review: THE YAKUZA
Review: THUNDERBOLT AND LIGHTFOOT
Review: VANISHING POINT
Review: WHITE OF THE EYE
Review: WINGS OF DESIRE
ROLAND JOFFE ON 'THE FORGIVEN'
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LIZZIE OLESKER is a Brooklyn based writer, director, and performer. Her plays and performances have been developed and seen at the Public Theater (Dreaming Through History), New Georges (Embroidered Past), Cherry Lane Theatre (Razing Houses), Ohio Theater, Dixon Place, Invisible Dog (Infinite Miniature) and Clubbed Thumb (A Kind of Mother). She's collaborated with the Talking Band at La Mama and HERE, and has directed Louise Smith's Dorothy Lane and Diane Torr's Donald Does Dusty. Her site-specific laundromat performance (Every Fold Matters) was developed into a hybrid documentary film The Washing Society, co-directed with Lynne Sachs, and seen at Anthology Film Archives, BAM, and the National Gallery of Art.
Lizzie's the recipient of grants and fellowships from New York Foundation for the Arts, Dramatists Guild, Puffin Foundation, and Brooklyn Arts Council. She has taught playwriting at Swarthmore College, the New School, and NYU Tisch School of the Arts.


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Q: How to do Class Loading in Tomcat How to do Class Loading in Tomcat
In my web app folder I have deployed a war and in that war there are some libraries which are clashing with my tomcat lib folder. Also, I don't want to remove any of my libraries.

A: If you are not ready to remove your libraries you can go on with removing those package with Tomcat AS.But could you be more accurate in your description.What are libraries that leads to conflicts? What are you packging in your war file?