text: Jeff, You should definitely consider PVFS or any other parallel filesystem over NFS mounting for concurrent scratch space. I read your requirements from another post and the number of writes, etc, and those writes would likely flood even the most respectable file server. PVFS2 has much improved fault tolerance over PVFS1 in that there can be redundant file nodes where as with PVFS1, if one node dropped dead, your FS was toast. If you go to their web site, there should be plenty of documentation on how to set it up. You may also want to consider investigating GFS from Red Hat and Luster. Brian Smith On Sat, 2004-10-30 at 12:41 -0700, Jeff Candy wrote: > Greetings, > > Does anyone have experience with PVFS on a cluster > in the range of 80 processors (40 dual nodes with > gigE)? > > I am considering this over the usual NFS-master > node stup since we expect to multiple users/jobs > running concurrently. > > I am interested to hear any information/horror > stories, etc. > > Thanks, > > Jeff > _______________________________________________ > Beowulf mailing list, Beowulf at beowulf.org > To change your subscription (digest mode or unsubscribe) visit http://www.beowulf.org/mailman/listinfo/beowulf


text:
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Table of Contents
> Anal fissure
Anal fissure
Related Terms
Signs and symptoms
Integrative therapies
Author information
Risk factors
Types of the disease
Integrative Therapy Quick Links:
Bovine cartilage
Cascara sagrada
Ozone therapy
Slippery elm
Related Terms
Abrasions, acute anal fissure, anal cancer, anal crack, anal fistula, anal pain, anal tear, anal ulcer, bariatric procedures, chronic anal fissure, constipation, Crohn's disease, dehydration, diarrhea, hemorrhoids, incontinence, infected surgical wounds, inflammatory bowel disease, inflammatory phase, laceration, perianal abscess, perianal fistula, pregnancy, primary anal fissure, rectal ulcer, secondary anal fissure, skin wounds, thrombosed external hemorrhoids, wound care, wound healing.
The anus is the external opening of the rectum (the final portion of the colon). A rip or tear in the skin of the anal canal is called an anal fissure. Anal fissures may result in anal bleeding, which is noticeable on toilet paper or in stool in the toilet. Pain is associated with both acute and chronic anal fissures. In general, the fissures extend from the anal opening and are located posteriorly in the midline. The depth of the fissure varies; it may be superficial or as deep as the underlying sphincter muscle (the muscle that holds the anus closed). An anterior fissure is very rare (10% of female and 1% of male cases).
Anal fissures are generally caused by stretching of the anal mucosa (moist tissue). This may occur because of constipation, passing hard and/or large stools, prolonged diarrhea, decreased blood flow to the area (as seen occasionally in older adults), childbirth, dietary choices, or inflammatory bowel disorders such as Crohn's disease. Anal fissures occur commonly in infants. Less common causes include anal sex and diseases such as cancer, HIV, tuberculosis, and syphilis.
The drug nicorandil (a potassium-channel activator) may increase the risk of anal fissure, although the available research is limited.
Anal fissures may affect all age groups, with an equal incidence in both sexes. In the United States, over 200,000 new cases of anal fissure are reported, and 40% persist for months to years. In pregnancy, up to one-third of women develop anal fissures and external hemorrhoids. Constipation and dyschezia (retaining stool in the rectum) during pregnancy are the main risk factors for their development.
Of current interest is the development of surgical treatments with fewer complications than lateral internal sphincterotomy (LIS), the current treatment of choice for chronic fissures. LIS generally has a high success rate. However, complications may include postsurgical pain, slow healing of the incision, and development of acute (during the surgical recovery period) and usually mild anal incontinence (lack of control of the bladder), including the inability to control gas, fecal soiling, and fecal loss.
Signs and symptoms
The main symptoms of an anal fissure are pain (chronic or with defecation) and rectal bleeding.
Anal fissures may result in anal bleeding, which is noticeable on toilet paper or in stool in the toilet. The blood is often bright red. The quantity may vary.
Pain is associated with both acute and chronic anal fissures, although the intensity is often greater in the acute form. In the acute form, severe pain is often associated with defecation.
Visual inspection may not be enough to detect anal fissures. Superficial or shallow anal fissures are often too small to be seen visually.
Other symptoms may include constipation or a rip in the skin that can be seen when the area is slightly stretched.
Diagnosis is usually initiated because of bleeding or pain associated with defecation. The healthcare provider can usually diagnose an anal fissure based on medical history and a rectal or visual exam.
A rectal exam may involve the insertion of a gloved finger into the anal canal. However, this is often too painful, and a visual exam only may be conducted. The visual exam may employ a short, lighted tube called an anoscope.
If the tear is visible, a diagnosis can be made. If the tear is not visible, a sample of the rectal tissue can be taken.
Generally, other tests are not needed. However, if signs and symptoms also suggest an underlying inflammatory bowel disorder or colorectal cancer, or if the healthcare practitioner wants to rule out other disorders, other tests may be conducted. These include flexible sigmoidoscopy (the insertion of a thin, flexible tube with a tiny video camera into the sigmoid (bottom part of the colon)), colonoscopy (the insertion of a thin, flexible tube with a tiny video camera into the entire colon), and anal manometry (the insertion of a thin, flexible tube into the anus and rectum for the expansion of a balloon to determine the tightness of the anal sphincter and function of the rectum).
Complications of anal fissures may result from recurrence, inability to heal, or from treatments used. The risk of a subsequent anal fissure is increased in persons who have had a previous anal fissure.
The main complication associated with acute fissures is an inability to heal. An anal fissure that does not heal within a few weeks becomes chronic. These anal fissures become deeper and form ulcers. If the anal fissure extends into the internal anal sphincter muscle (the muscle that holds the anus closed) and spasms, it may impair blood supply to the fissure, reducing the ability to heal. In the case of a chronic, nonhealing ulcer, infection by fecal bacteria (bacteria in the stool) is possible.
An increased risk of anal cancer is associated with previous development of anal fissures.
Complications may also occur from treatments used for anal fissure. Surgery is often used to treat a chronic anal fissure. Surgery for chronic fissure may result in the development of acute (during the surgical recovery period) or chronic, usually mild anal incontinence (lack of control of the bladder), including inability to control gas, fecal soiling, and fecal loss. Other complications of surgery include postoperative pain or slow healing of the incision, hematoma or ecchymosis (bruising), abscesses, hemorrhage, and urinary incontinence (lack of control of the bladder), as well as recurrent fissures.
Complications of botulinum toxin (another potential treatment) include gas or fecal incontinence, as well as blood clotting or bruising around the anus. Flu-like symptoms and swelling of the epididymis (the tube that connects the testicle with the vas deferens) have been reported rarely. Adverse effects are considered short-term and reversible.
Complications of topical nitroglycerin (occasionally used to relax the anal sphincter muscle) include headaches, low blood pressure, and dizziness. Anal itch and allergic dermatitis have been reported rarely.
Complications of increasing fiber in the diet include gas or bloating.
In infants, those with a previous episode of abscess or pus at the time of surgery were more likely to have recurring anal fissures.
Most fissures heal within a few weeks and do not require specific treatment. If treatment is necessary, first-line treatments are generally home-based. If the fissure does not heal and becomes chronic, further treatment, such as nonsurgical and surgical procedures, becomes necessary.
In infants, it is advised to change diapers frequently and ensure the infant is receiving enough fluids (breast milk or adequate water added to formula).
Home care methods
Home care methods can be used to treat most acute anal fissures. These include gentle cleansing, increased intake of fluids, regular exercise of 30 minutes daily on most days of the week, applying petroleum jelly to the area, using a stool softener, avoiding straining during a bowel movement, increasing fiber in the diet or use of fiber supplements, or using a sitz bath. Sitz baths involve soaking in warm water for 10-20 minutes several times daily. Fiber in the diet can be increased by increasing consumption of fruit, vegetables, beans, grains, and nuts. Fiber supplements include psyllium.
Nonsurgical treatments (medications)
In some cases, medications may be necessary. In general, these medications are used to relax the muscles or decrease pain around the anus. Medications include muscle relaxants or analgesic or anesthetic numbing creams, which are applied to the skin around the fissure.
Examples of creams include topical nitroglycerin, calcium channel blockers (nifedipine or diltiazem), and zinc oxide. Nitroglycerin cream increases blood flow to the fissure, promoting healing. Complications of topical nitroglycerin include headaches, low blood pressure, and dizziness. It is generally recommended that nitroglycerin ointment be applied while in a seated or lying down position to prevent dizziness. Exercising immediately afterwards is generally not advised. Nitroglycerin ointment is not advised within 24 hours in men using erectile dysfunction medications (sildenafil, tadalafil, vardenafil) due to the potential for effects on blood pressure.
Injection of onabotulinumtoxinA (botulinum toxin; Botox) into the anal sphincter (the muscle in the anus) is occasionally used to relax the anal sphincter by initially paralyzing it. Complications include pain at the injection site or anal incontinence (gas and fecal).
If the fissure does not heal within a few months, surgery may be necessary. Examples of surgical treatment for anal fissure include anal stretch (Lord's operation) or lateral sphincterotomy (LIS). The goal of these surgeries is to reduce sphincter spasm, allowing a return to normal blood supply.
Lateral internal sphincterotomy (LIS)
: LIS generally has a high success rate. It is usually a same-day surgery, with the patient under general anesthesia. It involves partially dividing the internal anal sphincter. This allows the blood supply to the area to improve and slightly weakens the sphincter. Recovery is often within one week. Complications may include postsurgical pain, slow healing of the incision, and the development of acute (during the surgical recovery period) and usually mild anal incontinence, including keyhole deformities (where the anal canal resembles an old-fashioned key) and inability to control gas, fecal soiling, and fecal loss. The use of three stitches may reduce complications associated with LIS.
Dermal flap coverage
: Dermal flap coverage (use of skin flaps for coverage of the fissure) is of interest in the surgical treatment of anal fissures due to reduced complications following this surgery.
Anal dilation
: Anal dilation involves stretching of the anal canal (Lord's operation). It is less commonly performed than LIS. Both fecal and gas incontinence are common adverse events of this procedure.
: Less common surgical treatments include anal advancement flap (diseased tissue cut away and good tissue sewn over the area), tailored anal sphincterotomy (sphincterotomy as described as above, but more sphincter is preserved), and fissurectomy (removal of the fissure).
Integrative therapies
Unclear or conflicting scientific evidence
: Arginine is a semiessential amino acid. In the body, it is converted to nitric oxide and aids in vasodilation (dilation of the blood vessels). Arginine also triggers the body to make protein and has been studied for healing wounds. Early research suggests that arginine helps heal chronic anal fissures, but additional studies are needed.
Use caution in patients with bleeding disorders or those taking drugs that may increase the risk of bleeding. Use caution in patients with diabetes or hypoglycemia or those taking agents that affect blood sugar. Use caution in patients with impaired kidney function, those at risk for high blood potassium (including those with diabetes), or those using drugs that elevate potassium levels (including potassium-sparing diuretics and potassium supplements). Use caution with phosphodiesterase inhibitors (such as sildenafil [Viagra®]) in postmenopausal patients, in patients with herpes virus, and in individuals at risk for headaches. Use caution in patients with immunological disorders, acrocyanosis, sickle cell anemia, hyperchloremic acidosis, or guanidinoacetate methyltransferase (GAMT) deficiency. Avoid in those with low blood pressure or those using blood-pressure lowering agents, in patients with asthma or breast cancer, in those at risk for or with a history of heart attack, or in those using nitrates or spironolactone. Avoid in pregnant or breastfeeding women. Avoid with known allergy or sensitivity to arginine.
: Ayurveda originated in ancient India more than 5,000 years ago and is potentially the world's oldest system of natural medicine. It is an integrated system of specific theories and techniques that uses diet, herbs, exercise, meditation, yoga, and massage or bodywork. The goal of Ayurveda is to achieve optimal health on all levels: physical, psychological, and spiritual. There is some evidence that a traditional Ayurvedic treatment using specially prepared alkaline threads (
or Ayurvedic setons) to achieve gradual cauterization may provide an effective alternative to surgery in patients being treated for anal fistulas.
Ayurvedic herbs should be used cautiously, because they are potent. Some constituents can be potentially toxic if taken in large amounts or for a long time. Some herbs imported from India have been reported to contain high levels of toxic metals. Ayurvedic herbs can interact with other herbs, foods, and drugs. A qualified healthcare professional should be consulted before taking Ayurvedic herbs. Use
cautiously with peptic ulcer disease. Avoid sour food, alcohol, and heavy exercise.
Mahayograj guggul
should not be taken for long periods of time.
Piper longum
) should be taken with milk and avoided with asthma. Avoid sweet flag, and avoid
Emblica officinalis
) at bedtime. Avoid
Terminalia hebula
) if pregnant. Avoid Ayurveda with traumatic injuries, acute pain, advanced disease stages, and medical conditions that require surgery.
: Clove is widely cultivated in Indonesia, Sri Lanka, Madagascar, Tanzania, and Brazil. It is used in limited amounts in food products and is used as a fragrance, flavoring agent, and antiseptic. There is some evidence that a clove oil cream may aid in relief from anal fissures.
Use cautiously with seizure disorders and kidney or liver dysfunction. Use cautiously in patients with low blood pressure or in those taking drugs that lower blood pressure. Use cautiously in patients taking estrogen. Use cautiously in patients with autoimmune disorders or in those taking drugs that suppress the immune system. Avoid if pregnant or breastfeeding. Avoid if allergic to balsam of Peru, clove, eugenol, or some licorice and tobacco (clove cigarette) products. Avoid with bleeding disorders and in pediatric patients. Avoid use of undiluted clove oil on the skin.
: Psyllium, also referred to as ispaghula or isphagula, is derived from the husks of the seeds of
Plantago ovata
. Psyllium contains a high level of soluble dietary fiber and is the chief ingredient in many commonly used bulk laxatives, including products such as Metamucil® and Serutan®. There is some evidence that psyllium reduces the number of surgeries necessary to heal anal fissures.
Avoid if allergic or hypersensitive to psyllium, ispaghula, or English plantains (
Plantago lanceolata
). Avoid in patients with esophageal disorders, gastrointestinal atony, fecal impaction, gastrointestinal tract narrowing, swallowing difficulties, or previous bowel surgery. Avoid ingestion of psyllium-containing products in individuals with repeated or prolonged psyllium exposure. Prescription drugs should be taken one hour before or two hours after psyllium. Adequate fluid intake is required when taking psyllium-containing products. Use cautiously with blood thinners, antidiabetic agents, carbamazepine, lithium, potassium-sparing diuretics, salicylates, tetracyclines, nitrofurantoin, calcium, iron, vitamin B12, other laxatives, tricyclic antidepressants (amitriptyline, doxepin, and imipramine), antigout agents, anti-inflammatory agents, hydrophilic agents, and chitosan. Use cautiously with diabetes and kidney dysfunction. Use cautiously if pregnant or breastfeeding.
Historical or theoretical uses that lack sufficient evidence
Bovine cartilage
: Bovine cartilage, as a dietary supplement, typically is a preparation of bovine tracheal cartilage. There is a lack of research on the effectiveness of this agent for anal fissures.
Avoid if allergic or hypersensitive to bovine cartilage or any of its constituents. Use cautiously with cancer, kidney failure, or liver failure. Avoid if pregnant or breastfeeding.
Cascara sagrada
: Cascara is obtained from the dried bark of
Rhamnus purshiana
, both a medicinal and poisonous plant. It is found in Europe, western Asia, and North America (from northern Idaho to the Pacific coast in mountainous areas). There is a lack of research on the effectiveness of this agent for anal fissures.
Cascara was formerly approved by the U.S. Food and Drug Administration (FDA) as safe and effective, but this designation was removed in 2002 because of lack of supporting evidence. Avoid if allergic or hypersensitive to cascara. Use cautiously in children, due to the risk of electrolyte loss, specifically low levels of potassium. Use cascara cautiously in elderly patients. Avoid using cascara with nausea or vomiting, inflammatory bowel disease, appendicitis, intestinal obstruction, acute intestinal inflammation, Crohn's disease, ulcerative colitis, appendicitis, ulcers, or abdominal pain of unknown origin. Avoid with other laxatives. Avoid if pregnant or breastfeeding. Be aware that prolonged use of cascara may lead to dependence and tolerance.
Ozone therapy
: Ozone molecules are composed of three oxygen atoms (represented as O3). Ozone exists high in the earth's atmosphere and absorbs solar radiation. Ozone therapists have used different forms of ozone to treat a wide variety of conditions. There is a lack of research on the effectiveness of this treatment for anal fissures.
Autohemotherapy has been associated with transmission of viral hepatitis and with a possible case of dangerously lowered blood cell counts. Insufflation of the ear carries a risk of tympanic membrane ("ear drum") damage, and colon insufflation may increase the risk of bowel rupture. Consult a qualified healthcare professional before undergoing any ozone-related treatment.
: Peony has been used in traditional Chinese medicine (TCM) prescriptions for centuries. There is a lack of research on the effectiveness of this agent for anal fissures.
Avoid if allergic or sensitive to peony. Avoid with bleeding disorders or if taking drugs, herbs, or supplements that increase bleeding risk. Use cautiously with estrogen-sensitive cancers or if taking drugs, herbs, or supplements with hormonal activity. Avoid if pregnant or breastfeeding.
: Chinese herbalists have relied on rhubarb rhizomes and roots for thousands of years. The rhizomes and roots contain powerful anthraquinone and tannin compounds that act as stimulant laxatives and astringents, respectively. There is a lack of research on the effectiveness of this agent for anal fissures.
Avoid if allergic or hypersensitive to rhubarb, its constituents, or related plants from the Polygonaceae family. Avoid using rhubarb for more than two weeks, because it may induce tolerance in the colon, melanosis coli, laxative dependence, pathological alterations to the colonic smooth muscles, and substantial loss of electrolytes. Avoid with atony, colitis, Crohn's disease, dehydration with electrolyte depletion, diarrhea, hemorrhoids, insufficient liver function, intestinal obstruction or ileus, irritable bowel syndrome, menstruation, renal disorders, ulcerative colitis or urinary problems. Avoid handling rhubarb leaves, as they may cause contact dermatitis. Avoid rhubarb in children under age 12, due to water depletion. Use cautiously with bleeding disorders, cardiac conditions, coagulation therapy, constipation, history of kidney stones, or thin or brittle bones. Use cautiously if taking antipsychotic drugs or oral drugs, herbs, or supplements (including calcium, iron, and zinc).
: Senna (
Cassia senna
) is an ingredient found in several commercial laxative products. It is a U.S. Food and Drug Administration (FDA)-approved nonprescription drug. Both the leaves and the fruit (pods) of senna are stimulant laxatives. There is a lack of research on the effectiveness of this agent for anal fissures.
Avoid with known allergy or hypersensitivity to senna, its constituents, or members of the Fabaceae family. Use cautiously in patients who have had an obstruction of the gastrointestinal tract, according to expert opinion. Use cautiously in patients with hemorrhoids, stomach ulcers, or inflammatory bowel conditions. Use cautiously in patients with a history of gallstones. Use cautiously in patients taking diuretics or other laxatives, as additional potassium depletion may occur. Use cautiously in patients using anticoagulants (blood thinners), due to the potential for excessive bleeding to occur. Use cautiously in patients taking digoxin, as increased side effects may occur. Use cautiously in children less than 12 years of age. Avoid long-term use of senna, due to the potential for side effects, some of which may be serious. Experts suggest that senna should not be used for longer than 7-10 days. Chronic use of laxatives may lead to "lazy-bowel syndrome," in which the stomach and intestines gradually lose the ability to contract without being stimulated by the laxative.
Slippery elm
: Slippery elm inner bark has been used historically in wound healing. There is a lack of research on the effectiveness of this agent for anal fissures.
Avoid if allergic or hypersensitive to slippery elm. Avoid if pregnant or breastfeeding.
is a large tropical tree native to Polynesia and Southeast Asia. The oil from
nuts has a long history of traditional medical use as a topical anti-inflammatory agent and for many skin conditions. There is a lack of research on the effectiveness of this agent for anal fissures.
Avoid if allergic or hypersensitive to
or any other plants in the same genus (
) or family (Clusiaceae). Use cautiously with bleeding disorders or if using anticoagulants. Use cautiously if using sedatives or operating heavy machinery. Avoid if pregnant or breastfeeding, due to a lack of scientific data.
Anal fissures can be prevented in infants by ensuring adequate intake of fluids and water added to formulas, as well as frequent diaper changes.
In adults, anal fissure can be prevented by the following: avoiding straining during defecation, avoiding constipation and/or passage of hard or large stools, avoiding prolonged diarrhea, avoiding chronic wetness around the anus, and avoiding rough toilet paper or other harsh types of anal hygiene or rectal irritation. Constipation can be avoided by increasing fiber and fluid intake in the diet and decreasing caffeine intake.
If a fissure is suspected, a lubricating ointment can prevent worsening.
Author information
This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).
Abramowitz L, Sobhani I, Benifla JL, et al. Anal fissure and thrombosed external hemorrhoids before and after delivery. Dis Colon Rectum. 2002 May;45(5):650-5.
Abramowitz L, Batallan A. [Epidemiology of anal lesions (fissure and thrombosed external hemorroid) during pregnancy and post-partum]. Gynecol Obstet Fertil. 2003 Jun;31(6):546-9.
Andiran F, Dayi S, Mete E. Cows milk consumption in constipation and anal fissure in infants and young children. J Paediatr Child Health. 2003 Jul;39(5):329-31.
Hancke E, Rikas E, Suchan K, et al. Dermal flap coverage for chronic anal fissure: lower incidence of anal incontinence compared to lateral internal sphincterotomy after long-term follow-up. Dis Colon Rectum. 2010 Nov;53(11):1563-8.
Kang GS, Kim BS, Choi PS, et al. Evaluation of healing and complications after lateral internal sphincterotomy for chronic anal fissure: marginal suture of incision vs. open left incision: prospective, randomized, controlled study. Dis Colon Rectum. 2008 Mar;51(3):329-33.
Madalinski MH. Identifying the best therapy for chronic anal fissure. World J Gastrointest Pharmacol Ther. 2011 Apr 6;2(2):9-16.
Madalinski M, Chodorowski Z. Why the most potent toxin may heal anal fissure. Adv Ther. 2006 Jul-Aug;23(4):627-34.
National Institutes of Health (NIH) Medline Plus. .
Natural Standard: The Authority on Integrative Medicine. .
Nordenvall C, Nyrén O, Ye W. Elevated anal squamous cell carcinoma risk associated with benign inflammatory anal lesions. Gut. 2006 May;55(5):703-7.
Novotny NM, Mann MJ, Rescorla FJ. Fistula in ano in infants: who recurs? Pediatr Surg Int. 2008 Nov;24(11):1197-9.
Rotholtz NA, Bun M, Mauri MV, et al. Long-term assessment of fecal incontinence after lateral internal sphincterotomy. Tech Coloproctol. 2005 Jul;9(2):115-8.
Sánchez Romero A, Arroyo Sebastián A, Pérez Vicente F, et al. Open lateral internal anal sphincterotomy under local anesthesia as the gold standard in the treatment of chronic anal fissures. A prospective clinical and manometric study. Rev Esp Enferm Dig. 2004 Dec;96(12):856-63.
Watson A, Al-Ozairi O, Fraser A, et al. Nicorandil associated anal ulceration. Lancet. 2002 Aug 17;360(9332):546-7.
Anal fissures are generally caused by stretching of the anal mucosa. In adults, this may occur because of constipation, passing hard and/or large stools, straining during defecation, prolonged diarrhea, pregnancy, childbirth, or inflammatory bowel disorders such as Crohn's disease.
Less common causes of anal fissures in adults include anal sex and diseases such as cancer, HIV, tuberculosis, and syphilis.
In older adults, decreased blood flow to the anus increases the risk of nonhealing wounds.
In infants, constipation and infrequent diaper changes are common causes of anal fissures.
Risk factors
Risk factors in the development of anal fissures include chronic constipation, passage of hard and/or large stools, straining during defecation, and prolonged diarrhea.
Diets low in fiber and water may increase the risk of straining during defecation and constipation and thus may increase the risk of anal fissure development.
Diets high in agents that may increase the risk of constipation, including caffeine, may increase the risk of straining during defecation and of constipation and thus may increase the risk of anal fissure development.
Spicy foods may aggravate symptoms of anal fissures.
Aging is a risk factor for anal fissures. Aging is often accompanied by decreased blood flow to the anus, increasing the risk of nonhealing wounds.
The potassium-channel activator nicorandil may increase the risk of anal fissure. Use of this agent is associated with increased anal ulcerations. However, the available research is limited.
Pregnancy and childbirth may increase the risk of anal fissures. In pregnancy, up to one-third of women develop anal fissures and external hemorrhoids. Constipation and dyschezia (retaining stool in the rectum) during pregnancy may be the main risk factors during pregnancy.
In infants, risk factors include infrequent diaper changes and constipation, often due to inadequate fluid intake. Infants with a previous episode of abscess or pus at the time of surgery were more likely to have recurring anal fissures. Early introduction of cow's milk may increase constipation and therefore the risk of anal fissures.
Other risk factors in adults include harsh anal hygiene (rough toilet paper), chronic wetness around the anus, rectal irritation, bariatric procedures for obesity, constant saddle vibration (in professional mountain bikers), the use of bidet toilets, sexual abuse, and inflammatory bowel disorders such as Crohn's disease.
Types of the disease
: Both acute and chronic anal fissures are possible. Fissures may be considered primary (with no known trigger) or secondary (there is a likely trigger).
Acute vs. chronic anal fissures
: Acute anal fissures are commonly associated with severe pain after defecation. Acute anal fissures are generally superficial or shallow and may be hard to detect visually. Acute fissures generally heal within days to weeks. Chronic anal fissures, lasting longer than about six weeks, are generally associated with less pain than the acute form of the disorder. These anal fissures become deeper (forming an ulcer), and healing is more difficult or does not occur. Internal anal sphincter muscle spasm impairs blood supply to the fissure, reducing the ability to heal. In the case of a chronic, nonhealing ulcer, infection by fecal bacteria is possible.
Primary vs. secondary anal fissures
: Primary anal fissures are most commonly located on the posterior anal midline and have no obvious trigger. A small percentage of primary anal fissures are located on the anterior midline. Secondary anal fissures are a result of inflammatory bowel disease, previous anal surgery, and disease (e.g., venereal diseases, skin disorders, infections, or tumors). Infections associated with secondary anal fissures may include tuberculosis, herpes, cytomegalovirus,
Haemophilus ducreyi
, and HIV. The location of secondary anal fissures may not be typical (lateral, etc.).
Copyright © 2011 Natural Standard (
The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.
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text:
Figure 1. Cohort identification. The first box represents all cases of cancer identified within the data set for each disease site. The second box depicts the cohort for each disease site after general restrictions. The final box represents the cohort for each guideline following guideline-specific criteria. These guideline-specific cohorts are not mutually exclusive and may overlap because more than 1 guideline may be applicable to a given patient. ESRD indicates end-stage renal disease; AXD, axillary dissection; XRT, radiation therapy; PMRT, postmastectomy radiation therapy; TT, total thyroidectomy; and CND, central neck dissection.
Figure 2. Hospital distribution of 100% concordance for each guideline, depicting the percentage of hospitals with 5 or more cases and providing guideline-concordant care to 100% of eligible patients treated. BCS indicates breast-conserving surgery; ER, estrogen receptor; IBC, invasive breast cancer; PMRT, postmastectomy radiation therapy; and XRT, radiation therapy. (See the "Identification of Existing Clinical Practice Guidelines" subsection of the "Methods" section for explanation of the grades.)
Customize your JAMA Network experience by selecting one or more topics from the list below.
Greenberg CC, Lipsitz SR, Neville B, et al. Receipt of Appropriate Surgical Care for Medicare Beneficiaries With Cancer. Arch Surg. 2011;146(10):1128–1134. doi:10.1001/archsurg.2011.141
© 2019
Objective To investigate receipt of appropriate surgical care in Medicare beneficiaries with cancer.
Design Retrospective cohort study.
Setting National Surveillance, Epidemiology, and End Results registry linked to Medicare claims data.
Patients Fee-for-service Medicare patients aged 65 years or older who underwent a definitive surgical resection for breast, colon, gastric, rectal, or thyroid cancer diagnosed between January 2000 and December 2005. Claims data were available from January 1999 through December 2007.
Main Outcome Measures Receipt of care concordant with established practice guidelines in surgical oncology in the aggregate and by hospital.
Results Concordance with guidelines was greater than 90% for 7 of 11 measures. All guidelines regarding adjuvant therapy had concordance rates greater than 90%. Only 2 of 5 measures for nodal management had concordance rates greater than 90%. At least 50% of hospitals provided guideline-concordant care to 100% of their patients for 6 of 11 guidelines. Patients receiving appropriate care tended to be younger, healthier, white, and more affluent, to have less advanced disease, and to live in the Midwest.
Conclusions We found a high level of concordance with guidelines in some domains of surgical oncology care but far less so in others, particularly for gastric and colon nodal management. Given the current national focus on improving the quality of health care, surgeons must focus on generating data to define appropriate care and translating those data into everyday practice.
There is currently a major focus on improving the quality of health care in America. Quality health care means delivering the right care to the right patient at the right time. To ensure such care is provided, we must first know what the right or appropriate care is and then be able to determine whether that care was provided. The practice of health care in America varies widely across both institutions and demographic populations; this is true across specialties and disease sites.1,2 This variation may reflect 2 things: (1) a lack of knowledge about the optimal approach to care; or (2) a lack of acceptance regarding currently defined standards of care.
We sought to use practice guidelines to investigate whether appropriate surgical care was provided to Medicare beneficiaries with a new diagnosis of cancer. We first determined the percentage of patients receiving guideline-concordant care at an aggregate patient level. We then analyzed the degree of variation in hospital-level performance to understand whether each guideline has been accepted into routine practice. Finally, we identified patient and institutional factors associated with the likelihood of receiving appropriate care.
We organized our study around the 3 areas in which a surgeon treating cancer must be proficient: (1) surgical management of the primary tumor; (2) evaluation and treatment of regional nodal basins; and (3) appropriate referral for multidisciplinary adjuvant therapy. We first identified existing disease-specific guidelines in each of these areas for 5 common cancers in which surgery plays an important role, including breast, colon, gastric, rectal, and thyroid cancers, based on the following criteria: (1) the guideline must be endorsed by a professional organization or society whose members are considered experts in that disease, addressed in a National Institutes of Health Consensus Statement, or included as a recommendation in the AJCC Cancer Staging Manual3; (2) cancer registry and/or administrative data must be sufficient to define concordance, including both the numerator (patients who received the recommended care) and the denominator (patients meeting inclusion criteria for the recommended care); and (3) all other treatments must be considered inappropriate care.
To classify the strength of a given guideline, we used the classification system published by the National Comprehensive Cancer Network (NCCN).4 The NCCN clinical practice guidelines are readily available, are widely used, span multiple cancer sites, and classify the strength of both the evidence and panel members' consensus supporting a recommendation. The NCCN identifies 4 guideline categories: grade 1 indicates that the recommendation is based on a high level of evidence and there is uniform NCCN consensus; grade 2A, the recommendation is based on a lower level of evidence and there is uniform NCCN consensus; grade 2B, the recommendation is based on a lower level of evidence and there is nonuniform NCCN consensus (but no major disagreement); and grade 3, the recommendation is based on any level of evidence but reflects major disagreement.
The Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute collects detailed data including stage at diagnosis, tumor morphology, first course of treatment, and demographic variables for persons with cancer living in a SEER region.5 The SEER data have been linked to Medicare enrollment and claims data to facilitate evaluation of treatment and outcomes of care across the cancer continuum.6
Patients diagnosed with breast, colon, gastric, rectal, or thyroid cancer as their first or only cancer between January 2000 and December 2005 were identified and linked to Medicare claims data from January 1999 through December 2007. We required that all patients have at least 1 cancer-specific surgical procedure between 30 days before through 365 days after diagnosis and be associated with a nonmissing hospital identifier. Patients were also required to be continuously enrolled in Medicare and have no health maintenance organization enrollment during this period.
Between 2000 and 2005, there were a total of 181 534 patients with breast cancer, 116 383 with colon cancer, 22 625 with gastric cancer, 41 857 with rectal cancer, and 10 453 with thyroid cancer identified. Criteria used to specify the cohort are shown in Figure 1. We excluded patients younger than 65 years at the time of diagnosis and those with end-stage renal disease or disability as their qualifying condition. Patients with stage IV disease, disease of an unknown stage (except for thyroid cancer), or a discrepancy in the death date reported by SEER and Medicare of greater than 3 months were also excluded.
Additional specific inclusion and exclusion criteria for the denominator and numerator for each guideline were applied and are available on request. For situations where there was a discrepancy or ambiguity between identified guidelines regarding appropriate criteria, we performed sensitivity analyses varying the inclusion criteria. Tumor size criteria for receipt of total thyroidectomy were varied between 1 and 2 cm. As conclusions did not change, results are presented only for a threshold of 1.5 cm. Because this study focused specifically on the surgical practitioner, guidelines that related to the receipt of adjuvant therapy were expanded to include a visit with a medical oncologist or radiation oncologist regardless of whether the patient received treatment. Medical oncologists were identified by an associated Medicare specialty code for medical oncology or hematology/oncology or by having submitted a claim for chemotherapy.7-9 Radiation oncologists were defined by a Medicare specialty code for radiation oncology or by having submitted a claim for radiation planning or administration.
Concordance was measured as the proportion of patients who met the numerator criteria among all patients who met the denominator criteria for each guideline. The concordance rate for each guideline was determined at the aggregate patient level by considering all patients with the relevant condition and at the hospital level by considering all hospitals that treated at least 5 patients with the relevant condition. This was done to ensure stability in the estimate of the hospital concordance rate. While patients treated at hospitals with fewer than 5 patients were excluded from the hospital-level analysis, they were included in the aggregate patient-level analysis. We report aggregate patient-level concordance rates with 95% confidence intervals. Generalized estimating equations were used to account for clustering at the hospital level when calculating 95% confidence intervals.10 For the hospital-level analysis, we determined the proportion of hospitals for which 100% of treated patients received guideline-concordant care as well as exact binomial 95% confidence intervals.
For each of the guidelines meeting our eligibility criteria, logistic regression models were built to investigate covariates associated with receipt of concordant care. Generalized estimating equations were used to estimate the logistic regression parameters, which allowed us to investigate both patient and known institutional factors while accounting for clustering at the institutional level. Because the logistic regression analyses were exploratory, we did not adjust the type I error rate to account for multiple comparisons; thus, P values should be interpreted cautiously. The number of significant associations (P < .05) in these analyses is greater than expected by chance if there were no associations in the data. All tests were 2-tailed. All data management and statistical analyses were performed using SAS version 9.2 statistical software (SAS Institute, Inc, Cary, North Carolina).
Eleven guidelines were identified and are listed in Table 1, showing the original sources, the year they were proposed, and whether the NCCN grades them as based on a high level of evidence (grade 1) or uniform consensus but a lower level of evidence (grade 2A).4,11-18 Given that we are using guidelines to represent appropriate care, we did not include any guidelines for which there was nonuniform consensus or major disagreement. The 11 guidelines include 5 for breast cancer, 2 for colon cancer, 1 for gastric cancer, 1 for rectal cancer, and 2 for thyroid cancer. They represent the following domains of surgical oncology care: 1 measure for surgery directed at the primary cancer, 5 measures for nodal management, and 5 measures related to adjuvant therapy. Table 2 provides a description of the cohort for each disease site included in this analysis.
Concordance with guidelines was greater than 90% for 7 of the 11 measures (Table 3). All guidelines regarding evaluation for or receipt of adjuvant therapy had concordance rates greater than 90%. The measures that evaluated breast cancer management had the highest concordance rates. These included radiation therapy or evaluation following breast-conserving surgery (99.2%), chemotherapy or medical oncology evaluation for estrogen receptor–negative breast cancer (98.1%), axillary dissection for node-positive breast cancer (96.7%), postmastectomy radiation therapy or evaluation for patients with more than 4 positive nodes, with positive lymph nodes and a tumor greater than 5 cm, or with stage III cancer (94.9%), and nodal evaluation for invasive breast cancer (91.8%). The lowest concordance rates were seen for central neck dissection for node-positive thyroid papillary cancer (72.7%), colon cancer nodal evaluation of at least 12 nodes (48.5%), and gastric nodal evaluation of at least 15 nodes (32.5%).
There was wide variation in the proportion of hospitals providing uniformly guideline-concordant care, ie, treating 100% of their patients according to the guideline recommendation (Figure 2). Fewer than 1% of institutions met this standard for colon cancer nodal evaluation or central neck dissection, while 93% provided either evaluation for or treatment with radiation for all patients following breast-conserving surgery. More institutions had uniformly concordant care for guidelines concerning adjuvant therapy than for guidelines dealing with surgery directed at the primary cancer or nodal management.
Table 4 summarizes the factors associated with increased or decreased likelihood of receiving concordant care by guideline. For a number of the guidelines, younger age, less aggressive disease, white race, higher income level, being married, and care at a hospital that participates in an oncology group were independently associated with higher guideline concordance. Patients treated in the Midwest were more likely than patients treated in the Northeast to receive guideline-concordant care for all measures; the direction of the effect for the South and West (as compared with the Northeast) varied by measure.
Using practice guidelines to define appropriate care, we found that more than 90% of all patients received recommended care for 7 of the 11 guidelines examined at an aggregate patient level. We also identified 6 measures for which at least half of the institutions were concordant with the guidelines 100% of the time. These high concordance rates suggest that the factors influencing clinical decision making are adequately captured in the current guidelines and that surgeons recognize the importance of these therapies. As a result, we were able to demonstrate that Medicare beneficiaries are highly likely to receive appropriate care and that this finding is consistent across hospitals.
For several of the guidelines related to nodal management, however, concordance rates were low and few hospitals provided appropriate care to all patients. Specifically, we found that published guidelines recommending examination of a minimum number of lymph nodes in colon and gastric cancer have not resulted in routine adoption of this practice in elderly Americans despite the inclusion of these recommendations in the AJCC Cancer Staging Manual. It is possible that despite apparent expert consensus regarding the importance of evaluation of a minimum number of nodes, the lack of definitive evidence supporting a particular threshold has left many health care practitioners (surgeons and/or pathologists) unconvinced. They may not believe that the potential benefits of more extensive lymph node harvests outweigh the added operative risks, perhaps particularly in older patients. The limitations of the evidence base supporting nodal evaluation and the difficulty in defining an appropriate nodal threshold for use in guidelines or quality measurement are well described in 2 recent reviews, a report from the Cochrane Collaboration regarding the extent of lymph node dissection for gastric cancer and a meta-analysis on colon cancer nodal evaluation.19,20
We observed a somewhat different pattern of concordance for central neck dissection for node-positive papillary thyroid cancer. A higher aggregate concordance rate of 71.6% was observed; however, in the hospital-level analysis, no institutions performed neck dissections in all of their patients. Instead, most institutions performed them in approximately 80% of patients. Possible explanations for these findings are that there is agreement that a central neck dissection constitutes appropriate care for most but not all elderly patients with node-positive papillary thyroid cancer and that the factors relevant to selecting patients for the procedure are not adequately captured by the current guideline inclusion criteria, at least in this population of elderly Americans. Such factors might include the presence of a macrometastasis rather than a micrometastasis or nodes detectable preoperatively or at the time of surgery rather than only on postoperative pathology review.
Several other explanations could account for the patterns observed in this study. Prior research on the Hospital Quality Alliance measures has suggested an association between the length of time guidelines have been in place and concordance rates.21 We found high concordance rates and minimal variation for the breast cancer measures, guidelines among the first to be developed in cancer care.
It is also possible that because referral for adjuvant therapy is a dichotomous decision, facilitating both compliance and measurement, it is easier for institutions to achieve consistent and high concordance rates on these measures than on guidelines measuring a continuous outcome such as number of lymph nodes examined. Alternatively or in addition, the fact that referrals result in reimbursement for the health care provider or the health care system while lymph node harvests do not may contribute to the higher concordance we observed for guidelines related to adjuvant therapy.
Finally, there is a suggestion in our data that the level of evidence on which a guideline is based is associated with the level of concordance. Six of the 7 guidelines with concordance rates greater than 90% were based on a high level of evidence, and all of the 4 guidelines with concordance rates lower than 90% were based on a lower level of evidence (Table 3). Similarly, 5 of the 6 guidelines for which more than 50% of institutions provided concordant care to 100% of their patients were graded as 1, while 4 of the 5 guidelines for which fewer than half of the institutions provided fully concordant care were graded as 2A (Figure 2). The role that level of evidence may play in acceptance of guidelines deserves further investigation.
This study has the usual limitations associated with analyses of large national databases, including incomplete capture of cases, loss to follow-up, and missing data, as well as the limitations of claims data such as variation in billing practices and coding inaccuracies. Additionally, because Medicare provides the only consistent and comprehensive national data source on medical services delivered, our analysis was limited to patients aged 65 years and older. A focus on older patients did allow us to study a particularly vulnerable population and one that makes up the majority of patients with gastric and colorectal cancers. However, breast and thyroid cancers are common in younger Americans, so our reliance on Medicare data represents a more significant limitation for these diagnoses.
We found a high level of concordance with guidelines in some domains of surgical oncology care but far less so in others, especially those associated with nodal management. Five of the 6 measures with wide acceptance into practice (as evidenced by the majority of hospitals providing recommended care to 100% of their patients) relate to appropriate referral for or receipt of adjuvant therapy. Given the current national focus on quality in health care, there is increasing pressure to develop measures to determine whether patients are getting appropriate care; however, within the surgical disciplines, there is a paucity of data to support what constitutes appropriate care. It is critical that surgeons focus on generation of the data necessary to inform clinical decision making and promote high-quality surgical care.
Correspondence: Caprice C. Greenberg, MD, MPH, Center for Surgery and Public Health, Brigham and Women's Hospital, One Brigham Circle, 1620 Tremont St, 4-020, Boston, MA 02115 (email@example.com).
Accepted for Publication: March 11, 2011.
Published Online: June 20, 2011. doi:10.1001/archsurg.2011.141
Author Contributions: Dr Greenberg had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Greenberg, Lipsitz, Jha, Gawande, and J. C. Weeks. Acquisition of data: Greenberg, Neville, and C. Weeks. Analysis and interpretation of data: Greenberg, Lipsitz, Neville, In, Hevelone, Porter, Jha, Gawande, Schrag, and J. C. Weeks. Drafting of the manuscript: Greenberg, In, Porter, and C. Weeks. Critical revision of the manuscript for important intellectual content: Greenberg, Lipsitz, Neville, Hevelone, Porter, Jha, Gawande, Schrag, and J. C. Weeks. Statistical analysis: Greenberg, Lipsitz, Neville, In, and Hevelone. Obtained funding: Greenberg and J. C. Weeks. Administrative, technical, and material support: Neville, In, Porter, and C. Weeks. Study supervision: Greenberg and J. C. Weeks.
Financial Disclosure: None reported.
Funding/Support: This work was supported in part by a grant from the American Surgical Association Foundation.
Role of the Sponsors: The sponsor had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript.
Disclaimer: This study used the linked SEER-Medicare database. The interpretation and reporting of these data are the sole responsibility of the authors.
Additional Contributions: We acknowledge the efforts of the Applied Research Program, National Cancer Institute; the Office of Research, Development and Information, Centers for Medicare and Medicaid Services; Information Management Services, Inc; and the SEER program tumor registries in the creation of the SEER-Medicare database. Scott Regenbogen, MD, MPH, contributed to study conception and design, and Katherine Corso, MPH, assisted with manuscript preparation.
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On August 23rd, before an estimated worldwide viewing audience of approximately 1
billion viewers, Miss Venezuela Stefania Fernandez's life changed forever as she was
crowned Miss Universe 2009 from Atlantis, Paradise Island, Bahamas. The win was a
milestone for the Miss Universe Organization as it was the first time that a country has
won back-to-back crowns in the pageant's storied history (following fellow Venezuelan
Dayana Mendoza's victory in 2008).
Hailing from Merida, Venezuela, 19-year-old Fernandez made the untraditional
decision to leave home at a very young age to start pursuing her dreams. Fernandez's
ambition lies in international relations and affairs, which is a natural precursor for her
role as Miss Universe. She is also interested in the importance of arts as a tool for
childhood education and free thinking.
Since early childhood, Fernandez has been regaled by her grandmother's stories of
world travel. "I loved hearing about the adventures of my elders, and I can only hope
to one day follow in their footsteps and experience the world." She originally entered
the pageant world to meet new people, garner valuable life experience and, most
importantly, learn English.
Fernandez, despite her more recent accomplishments, is no stranger to setbacks. After
leaving home at age 16, she began competing in beauty pageants in preparation of
one day contending for the Miss Universe title. She purports to have amassed a strong
sense of determination and resolve after a judge in one of her early regional pageants
told her that she would have no future in beauty contests. "When faced with
negativity and being told that I would never make it, the true competitor in me grew
stronger," says the 5'10 brunette beauty. "Even though I am young, I am fortunate that
I have been challenged by many people to abandon my goals. It gave me just
another reason to never give up and to never stop moving forward."
Fernandez comes from a close-knit family. Her father was kidnapped when she was 14-
years-old and she asserts that this traumatic experience helped her appreciate all that
she has.
In her free time, Fernandez is an avid swimmer and tennis player. She is a regular
volunteer with "Piensa en Arte" which helps children expand their creative thinking
capabilities through art.
Fernandez will spend her year championing the official causes of the Miss Universe
Organization. She will work to increase HIV/AIDS awareness by focusing on women's
health and reproductive issues. She will also work to forge new relationships with
organizations committed to research and education such as the Latino Commission
on AIDS, God's Love We Deliver, PSI/YouthAIDS and Gay Men's Health Crisis.


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If your coming to the IBM System z Technical University in Miami, Oct. 3 -7, make sure you stop by the zZone to meet the numerous IBM Destination z partner members. Their mission is to help you maximize your mainframe platform so you can sleep at night! Visit the zZone, grab a zZingo card and meet the zZone sponsors who strive to make your life better. Then, relax with a complimentary chair massage during exhibit hall hours as our thank you for visiting the zone!
IBM Destination z zZone Sponsors include:
- 21st Century Software
- Mainline Information Systems
- Trident Services
- GT Software
- OpenTech Systems, Inc.
- Intellimagic
- NewEra
- IBM Systems Magazine
- Innovation Data Processing
Yours in z,


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In a new study, 100% of people suffering from acute high blood pressure saw it go down significantly within hours of drinking a cup of beetroot juice. Importantly, blood pressure remained lower up to 24 hours later.The research, funded by the British Heart Foundation, was lead by Professor Amrita Ahluwalia, Professor of Vascular Biology at the William Harvey Research Institute (Barts Hospital, London) and has been published in Hypertension, the Journal of the American Heart Association. A sample of 8 women and 7 men with systolic blood pressures varying from 140 to 159 mm Hg were given 250ml of Beet It organic beetroot juice in a double blind crossover trial using a placebo (a depleted nitrate beetroot juice made especially for the project). An average reduction of 10 mm Hg was recorded in those drinking the nitrate rich juice, with both systolic and diastolic blood pressures being lowered. The effect was most pronounced 3 to 6 hours after drinking the juice. The results will be particularly welcomed by people with high blood pressure who prefer to use natural products to control the condition. High blood pressure has been linked with cardiovascular disease - the world's biggest killer - a cause of strokes and heart attacks. The beetroot juice supplied by Beet It, the UK's leading brand of beetroot juice, has a naturally high nitrate content. The research has clearly identified that this nitrate level is the reason it is so effective at lowering blood pressure. This nitrate (NO3) converts into nitrite (NO2) though interaction with enzymes in saliva which can be stored in body tissues where is can be reduced further to Nitric Oxide (NO) in the blood system. Nitric oxide is a signaling molecule that widens blood vessels, increasing blood flow and so reducing blood pressure. This also increases the blood supply and thereby oxygen supply to the muscles enabling them to work more efficiently. Beetroot juice has already been attracting a lot of attention from the sports world as Boris Johnson discovered to his surprise when congratulating David Weir, winner of the Paralympic marathon and 4 gold medal winner. In fact many medal winners from many nations were powered by "nothing more sinister than" little shots of concentrated beetroot juice. James White Drinks Ltd has been working closely with beetroot juice research teams throughout the world since 2008. It has recently expanded its beetroot pressing operations, helped by EEC funding. Located in Suffolk, the UK's only maker of Beetroot juice has worked with the scientific community developing its Beet It concentrated beetroot shots. It has recently launched two new beetroot juice blends (with Ginger and with Passionfruit) to widen the appeal of high beetroot content juice for those who find the original Beet It juice difficult to like! Lawrence Mallinson, owner of James White, which produces Beet It, said: "The William Harvey Research Institute has led the way in beetroot juice from the start. And as producers of Beet It, we are proud to be their beetroot juice supplier. We are now supplying around 40 universities world wide with Beet It." James White Drinks Ltd has footage of beetroot juice being pressed and bottled at Whites Fruit Farm, Ashbocking, Suffolk. It is available via the following link. https://vimeo.com/59470657
Email: firstname.lastname@example.com
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California Department of Transportation
Date: July 5, 2012
District: District 02
Contact: Lori Mathiesen
Phone: (530) 229-0511
Caltrans Awards $48.5 Million for Safe Routes to School
to Increase Safety and Health
REDDING - Caltrans today awarded $48.5 million of state Safe Routes to School Program funds for 139 projects to increase safety and help reduce injuries and fatalities among children in grades K-12 who walk and bicycle to school.
"Safety is Caltrans' number one priority," said Caltrans Director Malcolm Dougherty. "We are committed to providing the highest safety possible for our children as they travel to and from school in California."
Among the state-funded projects are new sidewalks, bicycle lanes, and other safety improvements. Caltrans chose each project based upon need, effectiveness, and how quickly it could be delivered. By improving safety, more kids are encouraged to walk and bicycle to school, resulting in healthier children while reducing greenhouse gas emissions and vehicle congestion.
More than $7 million of the funds were awarded to critical safety projects in rural counties. In addition, 82 projects totaling $28 million will create jobs and benefit at least one low-income school within each project.
Some of the notable local projects that received funding include:
Pioneer-Quincy Elementary School received $512,000 toward constructing a pedestrian path and bridge, sidewalks, and curb ramps.
Sequoia Middle School and Cypress Elementary School received $292,400 to construct raised medians and pedestrian refuge islands, sidewalks, and curb and gutter improvements.
Shasta Meadows Elementary School received $122,900 to construct sidewalk and curb ramps.
Happy Valley Primary received $480,000 to construct multi-use path, sidewalks, and curb ramps.
To date, the state and federal Safe Routes to School programs have awarded $472 million for safety projects around California's schools.
To view the entire list of SRTS projects that received funding, click here.
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Blues Excited to Land Bouwmeesterby Louie Korac / St. Louis Blues
The St. Louis Blues have coveted Jay Bouwmeester since last summer.
They've been rumored to be in on the NHL's current top ironman, with a need for a left-handed defenseman and a guy that can complement Alex Pietrangelo on the team's top defensive pairing.
Blues general manager Doug Armstrong finally got his man Monday night when he swung a trade for Bouwmeester, acquiring the 10-year veteran from the Calgary Flames in exchange for defenseman Mark Cundari, the rights to goaltender Reto Berra and a first-round pick in the 2013 NHL Draft.
If the Blues fail to qualify for the Stanley Cup Playoffs, the Flames will receive the Blues' fourth-round pick at this year's draft, while the first-round selection will be deferred until 2014.
"It's taken the better part of 10 months to find the piece," Armstrong said via conference call. "It goes back through when we were looking to add a player (last offseason). Jay was one of those type of players that when you look at someone in our age group, someone that could log a lot of minutes, he's an iron man obviously playing 600-plus games. He's a workhorse, he's everything that we had hoped to find."
Bouwmeester, 29, is the second left-handed defenseman to join the Blues in three days. The Blues acquired Jordan Leopold from the Buffalo Sabres on Saturday for a pair of draft picks in 2013. Bouwmeester has six goals and 15 points in 33 games for the Flames this season and is averaging 25:09 per game, which ranks 13th in the NHL.
"It's just exciting to have someone of Pietrangelo's caliber, [Kevin] Shattenkirk's caliber (and) Bouwmeester's caliber moving forward," Armstrong said. "You couple that with the rock-steady play of Roman Polak and Barret Jackman. So I'm really excited about our group now."
The 6-foot-4, 212-pound Bouwmeester has 300 points (71 goals) in 750 career games. He's played in 621 straight games. He's in the fourth year of a five-year contract.
"It's a real feather in the cap of our ownership group," Armstrong said. "It's one thing to buy a team and say you want to win. It's another thing to say you want to win and back it up with your money. Adding a player of Bouwmeester's caliber and also his contract at $6.6 million, I think shows everybody in the hockey community that we're in, we believe we're in our window now. This isn't a trade just for 15 games and a player run. This is a trade for next year and hopefully many years past that."
Armstrong and Flames GM Jay Feaster both were playing a game of tug of war today, with Armstrong holding firm on what he was willing to part with and Feaster offering a package of what he wanted for Bouwmeester, who had his best offensive seasons with the Florida Panthers. The Panthers selected him third overall in 2002.
Feaster reached out to Armstrong again after the Blues had acquired Leopold.
"I was talking to Jay Feaster, he was obviously focused and rightfully so on the franchise face of Jarome Iginla but when that transpired, he called after we made the Leopold deal and said, 'Are you still interested?' I said yes we are," Armstrong said. "(I) reconnected with our ownership group. They were still committed. We never really talked names before, or what he wanted, because he was never at the point of trading.
"I think Jay is looking to add first-round picks and to recalibrate his group. He has Pittsburgh's pick, he has his own pick and now he has our pick. So it's been a good week for Jay Feaster. But for our team, giving a first-round pick and Cundari and Berra is something we could afford to let go moving forward."
The Blues, who jumped back into eighth place in the race for the Western Conference playoffs after Monday's 4-1 win at Minnesota, made it very clear that they are going for it now.
"I think it tells our team we're committed to having success in St. Louis and we're not satisfied with our current standing," Armstrong said. "We're willing to poke, prod and do our part as management to improve the team. But ultimately, the responsibility lies with that core group of players that we haven't touched: David Backes, David Perron, T.J. Oshie, Pietrangelo, [Patrik] Berglund, [Alexander] Steen, [Andy] McDonald. That group is still here and we've added two pieces to that group. Ultimately they have to help us get the job done."
Blues coach Ken Hitchcock, an Edmonton, Alberta native like Bouwmeester, told reporters after the game he was glad to bring in another quality player.
"I've known Bouw, I've known his dad for a long time," Hitchcock said. "He's a minute-muncher, he's got great mobility, he's hard to play against because he's mobile, he's got a long stick, he knows how to defend.
"I've had Jay in international play and he's been a really, really good player at high-level games. He's going to be a real good addition for us."
Backes, the Blues' captain, told reporters the players found out during the game.
"Word kind of trickled in here but you can't get distracted by those things," Backes said. "He's not on the ice yet, so we've gotta win games and make plays without him until he gets in.
"It shows we're making some moves to bolster the group of guys we have in here. We feel we had a good group before but a great defenseman with a lot of experience never hurt anybody."


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SAN BERNARDINO >> A man who eluded capture for two months after allegedly fatally beating and stabbing his estranged wife pleaded not guilty to a murder charge Friday morning.
Edly Atherley, 29, returned to Southern California on Wednesday after surrendering to the FBI in Tampa, Fla.
"Detectives from San Bernardino Police Department went to Florida and brought him back. He was booked into West Valley Detention Center" in Rancho Cucamonga, said Supervising Deputy District Attorney Simon Umscheid.
Atherley has been charged with one count of murder and an allegation that he used a knife in the slaying of 28-year-old Ashley Atherley. The woman's body was found in his apartment in the 2600 block of West College Avenue in San Bernardino on Dec. 1.
Atherley had fled the scene by the time police arrived.
Authorities spent weeks tracking down Atherley and even posted a $10,000 reward for his capture. He was on the FBI's most wanted list.
There was a federal warrant for him for unlawful flight to avoid prosecution.
Then on Jan. 18, investigators received a tip on his whereabouts. About an hour later, Atherley, accompanied by an attorney, turned himself in to FBI officials.
"We're glad that he's been returned to California so he can face justice, and we can get justice for the family of the victim in this case," Umscheid said.
Atherley is scheduled to return to court Feb. 14 for a confirmation of counsel hearing.
Lisa Brock, a friend of Ashley Atherley's family, said Friday they want to see justice for their loved one.
"This is an unthinkable ordeal for any family to face but they understand that (Edly Atherley) has a right to a fair trial," Brock said. "In no way do they want to impede the court process. They're putting trust in our judicial system and letting it take its course."


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Christmas food and drink: my top picks
With Christmas just around the corner, I thought I would share some of my favourite food and drinks to enjoy at this time of the year.
First, you may be thinking about stocking up on drinks a few days ahead. If you fancy something warming to keep the cold away, I really like Drambuie, which is made with fifteen year old Speyside malt whisky. It's a very nice drink to sip by the fire on a cold night.
For something more refreshing, you can't beat a good gin and tonic. Using a good gin and a good tonic makes a real difference. It's also a great to have up your sleeve for unexpected visitors over the festive period. I always buy Bombay Sapphire, which is, amazingly, celebrating its 250th anniversary this year. Fevertree tonic is, in my opinion, the tonic to serve with gin, and, to my delight, is now sold in larger bottles. Just add a slice of lime and some ice for the perfect G&T!
Last year, I tried Vanessa Kimbell's recipe for orange and cinnamon brandy. It is just gorgeous. I've made it again this year, and have used it in the Christmas cake and homemade mincemeat. It makes a delicious drink on its own or in a cocktail, too.
If you are steering clear of anything alcoholic, or perhaps if you have drawn the short straw and are designated driver, I like to serve freshly squeezed clementine juice. It takes around three fresh clementines to make one small glass of juice. I am lazy and use my Magimix to extract the juice, but as clementines are quite small, you can juice them using a citrus juicer very easily.
And, if you fancy something hot, Steenberg's Christmas hot chocolate and tea are just lovely. Gently spiced and very warming. Highly recommended.
And now, to food. Firstly, if you have not made your Christmas cake, do not panic. It's not too late! I always make Delia Smith's last minute Christmas cake, which also adapts very well to gluten free/dairy free.
If you like cheese at Christmas, try and buy the very best you can afford – you can tell the difference. We love Colston Bassett stilton and Spenwood with quince cheese most of all.
My final tip is not to buy too much food. We never buy large boxes of chocolates and snacks, as the temptation is just to snack all day. We keep our meals delicious, and that is more than enough. You can also feel comfortable and happy after Christmas, rather than bloated and regretting having eaten so much.
I wish you all a very happy Christmas.
Charlotte x


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State administrators, governors, and others have been warning about the disruption and chaos that actual implementation of Real ID will likely bring. This is not mere speculation, however – one attempt to begin initiating early compliance with the law already created such enormous confusion and disruption that it had to be halted.
One of the Real ID Act's requirements is that names on compliant driver's licenses must exactly match individuals' names as held by the Social Security Administration. Noting this, officials in Alabama decided to get a head start on complying with that aspect of the law. The state's motor vehicles department (the Department of Public Safety or DPS), began sending letters to individuals whose records were mismatched, demanding that they correct the "erroneous" information on their driver's licenses.
The result was a fiasco. Thousands of panicked Alabama residents jammed DPS offices worried that they would lose their right to drive. And, because the state began its records review with the oldest records, many of the reported 65,000-80,000 drivers who got letters were senior citizens.
Many recipients of the letter – some of whom had been driving for 50 years or longer - became panicked that they would lose their means of traveling around the largely rural state. Many elderly drivers were also reportedly worried that their Social Security checks or pensions would be interrupted if they did not "fix" the problem right away. "Here are people who have been law-abiding citizens all their lives, and then they get this letter," state legislator Neal Morrison told the Associated Press. "It scared them to death."
Anyone whose name as recorded by the motor vehicles department differed by the slightest amount from the way their name was recorded by the Social Security Administration received a letter. Recipients were instructed that they had to visit a DPS office to "correct" their data before they would be allowed to renew their license. That included, for example, women who had changed their last name on one card but not the other after a marriage or divorce, people with nicknames, and even those with slight variations in their names, such as a middle initial appearing on one but not the other. In quintessential bureaucratic fashion, the letter informed individuals that the name as listed on their driver's license – though it might well be a person's preferred form of address – was "erroneous."
Many citizens were also angered by the delays and fees that they encountered when they tried to comply with the letter. One 70-year-old woman had to go to the motor vehicles office for three days straight, the AP reported, finally obtaining a new license on the third day after a two-and-a-half-hour wait. Then, she was asked to pay an $18 fee – the state's standard payment for a new or duplicate license – and she "hit the ceiling."Another cost for many was the need to pay additional fees to obtain a new or replacement birth certificate.
Apologetic DPS officials halted the effort in the face of all these problems (including calls from state legislators who had heard from their constituents), and promised to try to lessen the problems by clarifying their explanations of the situation in future letters. Nevertheless, the fact remained that the cause of the disruption was not going to go away: the looming reality of the REAL ID Act. As the Alabama officials explained, "Public Safety regrets the inconvenience, aggregation and confusion this has caused licensed drivers, but we are mandated to do this by federal law."
Alabama's unfortunate experience trying to get a jump on implementing just one aspect of the sprawling Real ID legislation is merely a glimpse of what states and their residents can expect over the next few years if implementation of this legislation proceeds as scheduled. Bureaucratic hair-splitting, confusing instructions, long waits, overwhelmed offices, missed work, infuriating bureaucratic runarounds, and additional fees are what this legislation promises for Americans. All for – what?
M.J. Ellington, "Your life on your license: Alabama a step ahead in national ID debate," The Decatur Daily News, May 13, 2005.
Mark Harrison, "License confusion possible," [Fort Payne, Alabama] Times-Journal, October 1, 2005.
Alan Elsner, "Road to digital driver's licenses chaotic," Reuters, October 10, 2005.
Associated Press and Decatur Daily News staff, "Alabama puts brakes on license notification," October 7, 2005.


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Welcome to the CRG Discussion Forum!Forum registration problems: Make sure you enter your email correctly and you check your spam box first. *Then* email KurtS2@gmail for help.Classified ads are not allowed on the forum.
Total Members Voted: 1
Camaroman 1969, the photos to upload have to be less than 100kb (pretty small) or they won't upload.
I have pics of the pad on the supposedly "KC" stamped block. Just having a hard time "up-loading them.
Camaroman I believe I posted a comment last week that may have been removed....I am not sure as it it not here. In the post is said 'don't hold your breath waiting for a pic' What I really meant to say was that 'I am holding my breath waiting for a pic'If my post was removed because it was inappropriate, I apologize. If I have alzheimers and never made the post, just entirely disregard anything I post.


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Trenton, NJ – Marking the first extensive reform of New Jersey's tenure law in over 100 years, Governor Christie today signed the Teacher Effectiveness and Accountability for the Children of New Jersey (TEACHNJ) Act, a sweeping, bipartisan overhaul of the oldest tenure law in the nation. The legislation transforms the existing tenure system to now provide powerful tools to identify effective and ineffective teachers, strengthen the supports available to help all teachers improve their craft, and, for the first time, tie the acquisition, maintenance, and loss of tenure to a teacher's effectiveness in the classroom. The new law, S-1455, is the result of nearly two years of consistent and vocal advocacy for real education reform by Governor Christie and good faith, bipartisan cooperation with members of the legislature, education reform advocates, and stakeholder groups. Governor Christie called on the legislature to take the next step in ensuring New Jersey has the best educators in the country by reforming the antiquated practice of Last In, First Out (LIFO), supporting differentiated pay for teachers, and banning forced placement so principals and teachers agree to all teacher assignments.
"This is a historic day for New Jersey and this new tenure law is an important step towards ensuring we have a great teacher in every classroom. After more than 100 years in existence, this Administration, Legislature and key reformers have done together what many considered to be impossible. For their leadership in this effort and for their partnership, I thank Senator Ruiz, Assemblyman Diegnan, the sponsors in each chamber, and the Legislature as a whole in this long, difficult, but bipartisan, effort to bring real and meaningful change to our education system," said Governor Christie. "We are taking a huge leap forward in providing a quality education and real opportunity to every student in New Jersey. But our work to develop laws that put students first is not done. Now is the time to build on this record of cooperation and results to put in place further reforms focused on our students by ending the flawed practice of Last In, First Out and supporting both differentiated pay and banning forced placements of teachers."
The signing of TEACHNJ represents the completion of another item in the bold education reform agenda Governor Christie outlined in September 2010 and has pursued aggressively over the last two years. The Governor's reforms are aimed at ensuring that all students in New Jersey, regardless of zip code, graduate from high school ready for college and career.
"With this historic signing we are revamping a century-old tenure law and creating fundamental changes that will help to ensure our students have the best leaders in the classroom," said Senator Teresa Ruiz. "This law represents nearly two years of work. It demonstrates that no matter what side of an issue you are on, when people are truly willing to work together - and to continue to work regardless of the disagreements that may take place - extraordinary things can happen."
"Tenure reform represents one of the most significant and landmark pieces of legislation this Legislature has acted upon," said Senate President Steve Sweeney. "Working in a bipartisan fashion and thanks largely to the guidance, dedication, and leadership of Senator Ruiz, we are overhauling an outdated law that brings reform to our educational system and protects the educational future of our students."
The TEACHNJ bill enacts three measures essential to improving the quality of educators in front of New Jersey classrooms.
The law for the first time in New Jersey history ties the acquisition of tenure to effectiveness rather than simply on how long an educator has been in the profession. Tenure will now be awarded only after two years of effective or highly-effective ratings, and will take four years instead of three years to attain, while providing a year of mentoring for all new teachers. Similarly, revocation of tenure will be predicated on effectiveness and tenure charges will automatically be brought against teachers and principals after two consecutive years without a rating of effective or highly-effective, except in circumstances where an educator has demonstrated modest improvement during that span and may be granted an additional year to achieve an effective rating. These provisions will help ensure that only those teachers who are consistently demonstrating success in serving our students remain in the classroom.
The law also dramatically reduces the time and cost it takes to remove educators who are repeatedly ineffective in improving student outcomes. Formerly, the process to remove a teacher could take several years and cost more than $100,000, providing a disincentive for districts to bring tenure charges against ineffective teachers. Over the past ten years, less than 20 teachers have lost tenure after charges of "inefficiency," which was most closely aligned with the definition of "ineffective." Under the new system, the time would be limited to 105 days from the time the written tenure charges are received by the Commissioner and is capped at $7,500 per case – which will be paid by the state.
Additionally, the law outlines requirements for providing support to help all educators improve by developing more meaningful evaluation systems and tying the results of those evaluations directly to professional development. In addition to mandating mentoring in a teacher's first year, the new evaluation systems will provide more meaningful feedback on teacher practice and will incorporate measures of what matters most – how well students are actually performing. Professional development will be tied to those evaluations, and corrective action plans will be mandatory when a teacher is rated ineffective or partially ineffective – providing the opportunity for improvement before tenure charges are brought for ineffectiveness.
"The passage of this bill, which was unheard of only a year ago, demonstrates that education reform is not a partisan issue. If we really put children first, the right thing to do is in reality quite simple," said Education Commissioner Chris Cerf. "Now, let's continue to move forward and take on the hard work to make sure that every child in our state graduates from high school truly ready for college and career."
Over the past two years, the Department of Education has worked with principals and teachers across the state to improve evaluation systems in order to help all educators continuously improve their practice. There are currently 30 districts scheduled to pilot new teacher and principal evaluation systems this coming school year in preparation for statewide rollout in 2013-14, as outlined in the TEACHNJ law.
"This is meaningful tenure reform that does what's best for our children while balancing the protection of due process for our principals and teachers," said Assemblyman Patrick J. Diegnan Jr. "This is real change that will ensure new teachers are properly trained and evaluated and that tenure charges are handled in a timely and professional manner. Our focus will be where it should be - making sure that our students have the best teachers in the classroom."
Since taking office, Governor Christie has worked to secure critical education reforms to better serve all New Jerseyans. These reforms include an expansion of charter school application approvals paired with more aggressive management and oversight for charter performance, the implementation of the Interdistrict School Choice program, making common sense changes to the school funding formula to increase fairness and attack fraud and abuse, raising state support to education to the highest level in history, and moving forward with bold reforms in the No Child Left Behind waiver to put in place a better accountability system and more effectively turn around failing schools. Earlier this year, the Governor signed the Urban Hope Act, establishing a pathway for the creation of high-quality alternatives for students in three low-performing districts.
Primary sponsors of the bill are Senators M. Teresa Ruiz (D-Essex), Kevin J. O'Toole (R-Bergen, Essex, Morris and Passaic) and Assemblymembers Patrick J. Diegnan. Jr. (D- Middlesex) Ralph R. Caputo (D-Essex) Jay Webber (R-Essex, Morris and Passaic), Albert Coutinho (D-Essex), Mila M. Jasey (D-Essex, Morris), Bonnie Watson Coleman (D-Hunterdon, Mercer), and Craig J. Coughlin (D-Middlesex).


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Hope's Nora Kuiper is a gold medal winner on both the track and in the classroom.
Hope's Nora Kuiper is a gold medal winner on both the track and in the classroom.
Last month Kuiper captured the gold medal in the 100-meter dash at the NCAA Division III track and field championships.
Today the Phi Beta Kappa student has been named the College Division Academic All-American of the Year in women's track and field by the College Sports Information Directors of America (CoSIDA).
Kuiper was chosen for the honor after being named one of 45 CoSIDA Academic All-Americans in women's track and field.
The national championship in women's track and field and the Academic All-American of the Year are both firsts for Hope. Kuiper is Hope's 38th CoSIDA Academic All-American.
Earlier this week she was named the winner of the Sheila Wallace-Kovalchik Scholar-Athletic Award as the outstanding female senior in the Michigan Intercollegiate Athletic Association (MIAA).
She earned All-American honors three times during her career. She finished fifth in the 100 meters at the NCAA Division III national meet in 2008, then won the 100 meters in 2009 with a time of 11.84 seconds, the best time in the nation on the season. In the process, she became the first Hope female track athlete in school history to win a national championship. Kuiper also finished second in the 200 meters in 2009.
Kuiper earned All-MIAA honors in track and field all four years at Hope. She was an eight-time MIAA champion, winning the 100-meter dash all four years for the Flying Dutch. She also won the 200 meters in 2008 and 2009, and was part of Hope's winning 4x100-meter relay teams in 2008 and 2009. She set the MIAA record in the 100 meters in 2008 with a time of 12.13 seconds, then broke that mark in 2009 with a time of 12.10 seconds.
Kuiper was named the MIAA's most valuable runner in 2009, and was also named the recipient
of the Jack Schouten Award, given to Hope's outstanding senior female student-athlete,
in 2009.
A chemistry major, Kuiper graduated from Hope in May with a grade point average of 3.93. She received numerous academic honors, including Phi Beta Kappa recognition and being named general chemistry student of the year and recipient of the Kleinheksel Award in Mathematics at Hope. She was named to the MIAA Academic Honor Roll four consecutive years, and also was named to the U.S. Track Coaches Association All-Academic Team.
Kuiper was a teaching assistant in Hope's chemistry department for three years, served on Hope's Student-Athlete Advisory Committee for two years and was a member of Omnicron Delta Kappa, a leadership society. She also gave a presentation at an American Chemistry Society conference on utilizing fluorescent spectroscopy in DNA protein-building.
In addition, Kuiper was a group Bible study leader, tutored at-risk elementary students in Hope's Children's After School Achievement (CASA) program, volunteered with Habitat for Humanity and participated in a mission trip to Mozambique. She plans to spend a year in Mozambique working on a project to improve water supplies.
A graduate of Parchment High School, Kuiper is the daughter of Scott and Ann Kuiper.
The 15 Academic All-America® College Division first team honorees have an average G.P.A. of 3.92. Five of the first team selections owned a perfect 4.00 G.P.A.
To be eligible for Academic All-America® consideration, a student-athlete must be a varsity starter or key reserve, maintain a cumulative G.P.A. of 3.30 on a scale of 4.00, have reached sophomore athletic and academic standings at his/her current institution and be nominated by his/her sports information director.
Since the program's inception in 1952, CoSIDA has bestowed Academic All-America honors on more than 14,000 student-athletes in Divisions I, II, III and NAIA, covering all NCAA championship sports.
ESPN The Magazine - winner of the 2006 and 2003 National Magazine Award for General Excellence - is a provocative and innovative sports publication. Full of insight, analysis, impact and wit, the oversized biweekly with a circulation of 1.9 million looks ahead to give fans a unique perspective on the world of sports.