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gross evidence of acute pancreatitis. Lipase is produced by the canine gastric mucosa which explains why inflammation or damage to the stomach can
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1 CANINE PANCREATITIS Michael D. Willard, DVM, Diplomate ACVIM-SA Professor of Small Animal Clinical Sciences Department of Small Animal Clinical Sciences College of Veterinary Medicine Texas Veterinary Medical Center Texas A&M University College Station, TX History and physical examination are, as always, critically important; but, they are not that helpful for ruling pancreatitis in. Rather, they are more useful for finding other problems that may be mimicking pancreatitis. Regarding signalment, Schnauzers and Yorkies are famous for acute pancreatitis, but these breeds get a lot of other diseases that cause vomiting. Furthermore, acute pancreatitis can be found in any breed of dog. Canine pancreatitis is classically considered to present with acute vomiting and anorexia. Abdominal pain is frequently present, but it is easy to miss during physical examination, and fever is occasionally seen. However, we are recognizing more and more and more cases in which a) vomiting is not as severe as we have come to expect, and b) in which we are initially strongly drawn to other diagnoses to the point that many of us are no longer sure what a typical case of canine pancreatitis is. Some dogs (especially those with pancreatic abscesses) may have relatively mild, intermittent, unimpressive vomiting and continue to eat a reasonable amount of food. Many of the severely ill patients may present in classic systemic inflammatory response syndrome (SIRS) which is what used to be called septic shock, until we found out that you can have the same thing occur with any cause of massive inflammation. Many dogs with very severe acute pancreatitis present as though they had an acute, septic abdomen. Some have substantial amounts of abdominal fluid. If acute pancreatitis is associated with or due to pancreatic carcinoma (rare), you may rarely see a dog that has widespread subcutaneous fat necrosis causing sterile abscesses that are typically painful and cause cutaneous discoloration. Most cases of canine pancreatitis seem to be temporally related to either ingestion of fat or lipemia associated with diabetic ketoacidosis. Trauma and drugs can also cause canine pancreatitis. Drugs that are suspected of causing pancreatitis in people and animals include azathioprine, sulfonamides, tetracycline, and potassium bromide. CBC's often show an inflammatory leukogram, but 1) this is a relatively nonspecific finding and may be due to any number of problems and 2) not all animals with acute pancreatitis have a notable leukocytosis. Degenerative left shifts and substantial toxicity of circulating WBCs can be seen if the patient is in SIRS. Likewise, thrombocytopenia due to DIC is not infrequent in severely affected patients. However, some animals with clinically severe pancreatitis have absolutely normal leukograms. There are no findings on CBC that definitively diagnose or definitively eliminate pancreatitis Serum biochemical panels are not as helpful as we would like. Serum lipase and amylase activities are insensitive (each is about 50%, and that is optimistic) and nonspecific for pancreatitis and should probably never be requested. Dogs with acute pancreatitis and even pancreatic abscesses have had normal serum lipase activities. We have also identified dogs with drastically increased serum lipase activities that have intestinal foreign objects or gastritis, but no
2 gross evidence of acute pancreatitis. Lipase is produced by the canine gastric mucosa which explains why inflammation or damage to the stomach can result in excessive serum lipase activity. Canine TLI is a little more specific than amylase and lipase, but it is still not a sensitive test (approximately 35%). Therefore, it too has very poor negative predictive value. We have seen plenty of dogs with pancreatitis that had normal serum TLI's. The immunoreactive canine pancreatic lipase assay (i.e., cpli or Spec cpl) appears to be the most sensitive (approximately 80-85%) test for pancreatitis available. There are a few false negative results with this test, but it is clearly much more sensitive than any other blood test available. The real question is how specific it is for clinically important disease (i.e., lesions of the pancreas that are causing clinical disease as opposed to microscopic lesions that are clinically silent). The biggest advantage is that if the cpli test is negative, it is much less likely that pancreatitis is the real problem and you need to look very hard for extra-pancreatic disease in the dog. Blockage of the main pancreatic duct due to swelling due to generalized pancreatitis, an intrapancreatic granuloma, or an abscess that subsequently blocks the pancreatic duct may cause extrahepatic biliary tract obstruction (EHBO) with a notable increase in serum alkaline phosphatase and serum bilirubin. Pancreatitis is probably the most common cause of EHBO in the dog. Thus, while EHBO is very suggestive of acute pancreatitis (assuming that the patient does not have a mucocoele, which is usually easy to detect with ultrasound), relatively few dogs with acute pancreatitis develop EHBO. Furthermore, there are reasons for this triad of signs besides acute pancreatitis and extrahepatic biliary tract obstruction (e.g., cholangitischolangiohepatitis). Ultrasonographic evaluation of the abdomen (discussed below) is particularly helpful in these patients. Plain abdominal radiographs help eliminate other diseases which may mimic acute pancreatitis. Not finding evidence of other abdominal disease (e.g., foreign object) is helpful in eliminating obstruction and narrowing the list of differential diagnoses. Occasionally, one finds radiographic signs which specifically suggest acute pancreatitis. A sentinel loop (i.e., a dilated, air-filled segment) in the descending duodenum, and/or lack of serosal detail in the upper right abdominal quadrant, and/or lateral displacement of the descending duodenum on the ventrodorsal projection, and/or a mass medial to the descending duodenum (on the ventro-dorsal projection) and/or a mass just behind the liver and just below the pylorus (on the lateral projection) are somewhat suggestive of acute pancreatitis. These findings are only meaningful if present; many dogs and cats with acute pancreatitis do not have any of these radiographic findings. Probably the most greatest value of abdominal radiographs is that they help eliminate other diseases that could be causing signs similar to those caused by pancreatitis. Abdominal ultrasonography often finds abnormalities that suggest or are consistent with pancreatitis as well as eliminate other potential causes of vomiting and abdominal pain. Ultrasonography has been suggested to be about 40-70% sensitive in finding canine pancreatitis. One may sometimes detect hypoechogenicity surrounded by hyperechoic fat in the region of the pancreas that is due to pancreatitis. At other times, a markedly thickened pancreas may be found. Both findings are very specific evidence of pancreatitis. Evidence of EHBO (i.e., dilated bile ducts, not just a big gall bladder) is very suggestive of pancreatitis. Rarely, you will find dilated bile ducts due to inflammatory biliary tract disease, but this is not nearly as common a cause as is biliary tract obstruction. Any dog with extra-hepatic biliary tract obstruction (that does not have a mucocoele) and that is vomiting/anorexic should be assumed to have pancreatitis
3 until proven otherwise. It is very important to note that the ultrasonographic appearance of the pancreas can change dramatically within a few hours, so repeating abdominal ultrasound on the same day is not necessarily a bad idea if you strongly suspect pancreatitis but are finding nothing. Diagnosing pancreatitis during laparotomy is the least desirable method of diagnosis. Some patients present exactly like acute septic peritonitis but are ultimately diagnosed as having non-septic pancreatitis. There is nothing wrong with doing an exploratory laparotomy in a patient in which septic abdomen is a major consideration, only to find out that the patient has non-septic pancreatitis. We very rarely have reason to biopsy a normal appearing canine pancreas, and what grossly appears to obviously be pancreatitis in the dog seldom requires a biopsy unless carcinoma is a concern. However, you should never simply look at what appears to be an obviously neoplastic mass in the pancreas and make a diagnosis of carcinoma without biopsying it, no matter how extremely terrible it appears. Pancreatitis is much more common than pancreatic carcinoma, no matter how bad the pancreas looks or how many adhesions are present. If you biopsy the pancreas, it is important to obtain a biopsy that goes deeper than the superficial necrotic surface or adhesions. Cytology can be useful for making a presumptive diagnosis; however, I have seen at least one case in which cytology of a pancreatic mass was read out as carcinoma by two accomplished cytologists and yet multiple biopsies all came back as necrotic pancreatitis. Anecdotally, there appears to be more risk of causing iatrogenic pancreatitis with surgery in the dog than in the cat. Maintaining excellent mesenteric perfusion during anesthesia and performing the surgical biopsy with reasonable care and good technique minimizes the risks. Laparoscopic biopsy of the pancreas might be safer than surgical biopsy, but that is just anecdotal at this time. Chronic pancreatitis (i.e., chronic pancreatitis with intermittent, relatively mild recurrences) can be challenging to diagnose. Dogs with episodic vomiting due to recurrent bouts of pancreatitis may not have any other signs of disease, and they invariably are admitted to your clinic for a work up after the last bout has run its course or is on the mend. Episodes of vomiting and anorexia due to recurrent pancreatitis can be random and unpredictable. In such patients, the previously mentioned diagnostics may be attempted, especially when acute exacerbations occur. Very rarely, upper gastrointestinal barium contrast radiographs may rarely reveal duodenal abnormalities (e.g., dilatation, stricture) which suggest that recurrent bouts of acute pancreatitis have caused scarring of the pancreas which in turn have compromised the maximum size of the duodenal lumen. Ultrasonographic changes are nice if they are present, but they can be minor making it difficult to accurately interpret them. Feeding an ultra-low fat diet for 3-4 times longer than what was previously the longest interval between episodes may sometimes be helpful in making a presumptive diagnosis. If episodic vomiting/anorexia does not recur while feeding such an ultra-low fat diet for an interval so long that you would have been sure to experience another episode, then we can often assume (rightly or wrongly) that the signs were due to pancreatitis (or perhaps some other dietary-responsive disease). Anytime you find exocrine pancreatic insufficiency (diagnosed with TLI) in a breed that is not commonly affected with pancreatic acinar atrophy (e.g., German shepherd, rough-coated Collie), then chronic pancreatitis becomes a major concern. Pancreatic abscesses in dogs (as opposed to cats) are invariably sterile. Affected dogs typically can have a much more chronic, smoldering course (e.g., vomiting for a month or more, mild loss of appetite) than most dogs with more typical acute pancreatitis. We have even found a
4 few dogs which had pancreatic abscesses that were completely asymptomatic. Abdominal pain may be present or absent. CBC and serum biochemistry findings are unpredictable. Diagnosis requires ultrasound. Treatment may be surgical marsupalization, percutaneous ultrasonographic drainage or just observation. As of this writing, there is not a single, well-designed, robust, prospective, stratified study on the treatment of canine acute pancreatitis. Therefore, all any of us has is opinions, period. Nothing per os (NPO) has been the classic therapy for pancreatitis for many years. While it is true that they feed people with pancreatitis earlier than we feed dogs, you must remember that human pancreatitis is unassociated with dietary fat. People get pancreatitis from alcohol, trauma, gall stones and MOF (multiple organ failure). Canine pancreatitis is associated with dietary fat (as well as surgical trauma when poor technique is used around the pancreas). Some preliminary work from in Australia suggests that it is safe and perhaps beneficial to feed dogs with acute pancreatitis per os or with an esophagoscopy tube as soon as they can tolerate it (i.e., they do not get worse, even if they are still vomiting). I recommend that a) you feed as low a fat content as possible, and b) if the feeding is associated with worsening of the vomiting, that you stop it and either try again in a day or two, or go to jejunostomy feeding. Do not try to get full caloric intake into the patient; rather, start with small amounts to see if the patient will hold down the food. Obviously, if feeding is associated with worsening of the vomiting or general condition, stop the feeding. I generally start feeding potato or rice (i.e., no fat) and gradually work my way up to commercial diets with low fat content. Fluid therapy is critical, and subcutaneous administration of fluids is clearly inferior to IV fluids for all but mildly affected animals. IV fluid administration is often sufficient, even in dogs in which a pancreatic granuloma has temporarily blocked the main bile duct. Adequate pancreatic circulation is probably crucial for healing damaged pancreatic tissue; therefore, it is probably better to provide a little too much fluid rather than a little too little fluid unless the patient has congestive heart failure or oliguric renal failure. The abdominal viscera is not "first in line" to receive circulation when the patient is dehydrated (which most dogs with pancreatitis are when they come to your office). Obese and fat dogs (which describes a lot of dogs with pancreatitis) do not necessarily have skin tenting when they are dehydrated. Likewise, although you might expect dry, tacky oral mucus membranes, a nauseated animal may be salivating enough to make the mucus membranes moist even though it is dehydrated. If a vomiting dog is not eating or drinking, then it is dehydrated regardless of how well hydrated it appears on physical examination. However, if you give substantially too much crystalloid and dilute the serum protein concentrations, this could be detrimental. One should monitor the serum albumin concentration during fluid therapy in these patients. If the serum albumin concentration decreases significantly (i.e., to < 2.0 gm/dl), then the plasma oncotic pressure likewise decreases which diminishes the effective perfusion at the capillary level. Since perfusion is so critical to treating dogs with pancreatitis, one should probably become concerned whenever the serum albumin concentration falls below 2.0 gm/dl. It is very hard to administer enough plasma to significantly raise the plasma albumin concentration. Half of the albumin in the plasma that you administer will end up in the extravascular compartment instead of the intravascular compartment. Hetastarch is a better choice because it will stay in the circulation and raise the plasma oncotic pressure for much longer than plasma. Human albumin can be used effectively, but it occasionally causes anaphylactoid reactions that can kill the patient; therefore, it is not recommended. Canine albumin is safer, but it does not
5 last as long as hetastarch. There is some thought that plasma might be more effective than administering hetastarch because plasma might also restore circulating protease inhibitors and replenishe AT III (which is a treatment for DIC). This is a very contentious point. One retrospective study has shown that plasma did not help treat dogs with pancreatitis; however, this study suffers from the problems inherent in all retrospective studies. If the patient cannot tolerate early refeeding (i.e., the vomiting becomes worse), then jejunostomy feeding is another option. It is safter, less expensive, and less dangerous than parenteral nutrition, and has been associated with a better prognosis. In particular, it should be considered if an exploratory laparotomy was performed when the pancreatitis was diagnosed because a J-tube can be placed at that time. Alternatively, one can place a jejunostomy tube via laparoscopy, through a G-tube, and via the nose (naso-jejunostomy). Antiemetics are useful in patients that are vomiting repeatedly or that feel so nauseated that they feel terrible. I prefer to only use antiemetics for short periods of time because I want to see if the patient is improving enough so that it no longer needs the antiemetic to stop vomiting. However, if the patient is vomiting multiple times per day or obvious feels terrible due to the nausea, then maropitant (1 mg/kg SQ) appears to be very useful. Maropitant might also have the advantage of providing some analgesia because it blocks Substance P binding. Dolasetron ( mg/kg qd) and ondansetron (0.25 mg/kg qd) can also be effective. H-2 receptor antagonists have been used to prevent gastric ulceration and erosion. It is doubtful that ulceration/erosion is a common problem in all but the sickest patients. Furthermore, if it is desired to provide some level of protection to the gastric mucosa, the proton pump inhibitors are far superior to the H-2 receptor antagonists. Pantoprazole (1 mg/kg IV qd) or omeprazole (1.5-2 mg/kg PO bid) are the most commonly used drugs. I suspect that they provide more benefit by being antidyspepsic in nature (thereby making the patient feel better) than they do by preventing ulcers, but that is a guess. Antibiotics have been used to prevent secondary bacterial infection of the inflamed pancreas, which is supposed to be "fertile ground" for infection. However, there is minimal evidence that bacterial infection is of any significance in routine canine pancreatitis. Antibiotics do not hurt these patients, but it is very questionable how helpful they are. However, dogs in SIRS due to pancreatitis may be a different story. Any dog in SIRS from any reason is potentially at increased risk of infection due to severely compromised mesenteric circulation. Drugs designed to decrease pancreatic secretion have been disappointing, which is not surprising when one considers that acute pancreatitis may be associated with pancreatic hyposecretion instead of hypersecretion. Corticosteroids are very controversial in the treatment of pancreatitis. While they increase serum amylase and lipase activities, they do not cause pancreatitis. It is possible (this is controversial) that they may be useful in treating patients that are in Systemic Inflammatory Response Syndrome (i.e., SIRS, which used to be called septic shock ) due to the pancreatitis. At this time, there are good data showing that it is probably reasonable to give physiologic doses because dogs in SIRS typically can have what has been termed Critical illness related corticosteroid insufficiency (CIRCI), that is to say that they are relatively hypoadrenal. This is a controversial statement. If steroid therapy for pancreatitis is contemplated, it should probably be reserved for the severely ill dog which is not responding to fluid resuscitation. If steroid therapy will be administered, you need to warn the owners of the unknown nature of this therapy. A larger question is whether steroids may be useful in treating the inflammation found in severe
6 pancreatitis. We have some minimal evidence at this time that anti-inflammatory doses of steroids might (?) be helpful in some patients. At least, the steroids did not overtly hurt the patient, and it got better (either because of or inspite of the steroids). Although heparin therapy used to be the treatment for DIC (which can probably make acute pancreatitis worse), it has not been shown to be useful. If DIC appears to be a major problem, aggressive administration of fresh frozen plasma to replace clotting factors and antithrombin III concentrations is probably more effective. Analgesics can be very useful. One must remember that dogs are clearly much tougher than people, and they often hide their pain well. Unless there is some good reason to the contrary, it is best to routinely assume that dogs with acute pancreatitis are in pain and will benefit from analgesic. In mild cases, butorphanol is sufficient. In moderate cases, methodone is reasonable. As the pain becomes more severe, we progress to constant rate infusions of fentanyl. Is the most severe cases, we adminster a constant rate infusion of fentanyl, lidocaine and ketamine. Taking a dog with pancreatitis to surgery is probably one of the hardest decisions in small animal internal medicine. Strict guidelines cannot be given, but some basic principals may be suggested. In general, one must realize that unless an abscess, pseudocyst, mass of necrotic tissue, and/or an obstructed gall bladder with a bacterial infection are found, surgery will probably not benefit the patient (and may even be detrimental -- anesthesia is usually associated with some decrease in visceral perfusion unless great care is taken to maintain circulation). The basic idea is to try to find reasons why you should NOT do surgery, only doing surgery if you cannot find any good reason to avoid it. Ultrasonography usually finds the type of lesions that would be benefitted by surgery (i.e., abscess or pseudocyst). If one is uncertain whether or not a cyst or abscess might be present and might be responsible for appropriate medical therapy being ineffective, one may reasonably decide to explore the abdomen. However, this decision should be based on the finding that 5-7 days of excellent, aggressive supportive medical management has not been of any appreciable benefit. The best to determine if the patient is improving is to look at the patient. CBC, cpli, and ultrasound may all look worse in a patient that is clinically better. Trust the patient, not the imaging or the lab work, to know if it is improving. Do not be in a hurry to take dogs with pancreatitis to surgery; but, if you need to do surgery, then you should do it without any further delay. That is why it is important to provide the best possible medical management when first confronted with the patient with suspected acute pancreatitis. I will usually try aggressive medical therapy for 5-8 days, depending upon how quickly the patient is decompensating. If I have no indication that optimal medical therapy is helping after 7-9 days, then I will seriously consider surgery. If the patient has an EHBO, I generally will wait a longer time (i.e., a week or more, assuming that the patient is improving) before I consider surgery to relieve the obstruction. Almost all of these patients will eventually have the EHBO resolve if aggressively treated medically. If it appears important to relieve EHBO (the problem has been going on for 2+ weeks or the biliary tract might be infected), then percutaneous drainage using ultrasound guidance might be appropriate. Rarely a stent can be placed in the bile duct. If a pseudocyst or abscess is not found, lavaging the area and resecting obviously necrotic tissue might help the patient, but this is uncertain. Prognosis is difficult to predict. Hyperbilirubinemia is not necessarily a poor prognostic sign; pancreatic granulomas causing icterus due to obstruction of the bile duct typically resolve if
7 the patient receives appropriate supportive therapy. Hypocalcemia, while a poor prognostic sign in people, is infrequently found in dogs and cannot be used to predict the outcome. Pancreatic abscesses are usually sterile. We cannot correlate the ultrasonographic appearance of the pancreas with prognosis. Finding a degenerative left shift and/or a marked thrombocytopenia (probably due to DIC) are not known to be prognosticators, but one intuitively fears that a poor outcome is more likely with such findings. Evidence of SIRS is probably the most important reason to give a poor prognosis. When to send the patient home is the last question. The patient is sent home when it is doing well. Monitoring the ultrasonographic appearance or the cpli is much less valuable than observing the patient. If the patient feels good and is eating and is not vomiting, then you can probably send it home regardless of what the ultrasound looks like or how high the cpli is. When the dog is sent home, it should be on a very strict diet that is free of fat. If you tell them fat free and explain the hidden sources of fat in the diet, then maybe you will achieve low fat. If the dog ever gets sick again, they should come in and see you sooner rather than later, in case it is pancreatitis that is recurring.
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This light-weight app periodically checks temperature from Internet and alerts you if it is beyond your specified low and high range with a method of choice sound, vibration, LED light etc. Frequency of check can be controlled.
To do:
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Background image update based on weather
Great :)

subset: commoncrawl


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Iguaçu Falls: The Argentinian Side
Our visit to the Argentinian side of Iguaçu Falls, one of the New Seven Wonders of Nature.
Our visit to the Argentinian side of Iguaçu Falls, one of the New Seven Wonders of Nature.
Our visit to the Brazilian side of Iguaçu Falls, one of the New Seven Wonders of Nature.
The Urban Adventures Lima Discovery Tour is the best way to get a small taste of Lima's culture and history in a short period of time.
Lima's food scene has exploded over the last several years and I was excited to finally try a couple of the hot spots.
Chef Margot Janse and her talented team offer a contemporary African-inspired 8-course tasting menu unlike any other meal I've experienced.
We went to South Africa for the 6th time, but this was the first time we visited in October… peak time for whale watching!
The Southernmost Tip of Africa where two oceans collide: the Atlantic Ocean on the west and the Indian Ocean on the east.
Blaauwheim Guest House is located in Somerset West, a perfect location for exploring Cape Town and the Cape Winelands.
A few of my ideas on where to stay, where to eat, and how to avoid the crowds in Venice.
It's more than a meal. It's an opportunity every meat-eater should consider doing at least once.
Where to stay, what to do, and where to eat when visiting Lake Garda, the largest lake in Italy.
The highlight of our time in Torri del Benaco was a cooking class at Le Gemme di Artemisia, a hillside restaurant overlooking Lake Garda.
BMW European Delivery is nearly identical to placing an order for US delivery. The biggest difference is it's a lot more fun!
These Tequila Chipotle Chicken Wings have the perfect combination of heat, sweet, smoke, and tang.
These Vietnamese Chicken Wings are salty, sticky and have a punch of Asian flavor I'm sure you'll love.


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Theodore makes 28 saves, Wild beat Oilers 3-1
EDMONTON, Alberta (AP) -- Jose Theodore made 28 saves and Pierre-Marc Bouchard and Mikko Koivu assisted on all three Minnesota goals in the Wild's 3-1 victory over the Edmonton Oilers on Friday night.
Brent Burns, Jared Spurgeon and Andrew Brunette scored to help Minnesota win for just the third time in its last 14 games. Teemu Hartikainen scored for Edmonton. The Oilers, headed for their second straight last place finish in the NHL, have lost 13 of their last 15.
The Oilers' Theo Peckham and Wild defenseman Clayton Stoner got the game off to a rough start with a prolonged fight at center ice immediately after the opening faceoff.
It launched a violent first period that featured several scuffles.
Minnesota was given a 7-minute power play after a one-sided scrap when Edmonton's Steve MacIntyre jumped Brad Staubitz after the Wild forward took a run at rookie Magnus Paajarvi.
Just over a minute into the long power play, the Wild gave some of that advantage back when Cal Clutterbuck was given a major penalty for running Peckham into the boards.
However, the Wild did get a goal near the end of the power play when Burns scored on a 4-on-3 advantage with Edmonton's Chris VandeVelde also in the penalty box, serving a double minor for high-sticking.
Minnesota went ahead 2-0 early in the second when Bouchard's shot deflected off a defender to Spurgeon in front of the slot for an easy tap-in past goalie Devan Dubnyk.
Less than 1½ minutes later Edmonton, responded with Hartikainen's tap-in goal.
Edmonton came close to tying it with 8 minutes to play in the second, but a power-play shot by Jim Vandermeer rattled off of the post. The Oilers looked to have scored on the power play with 5 minutes left as the puck was pushed in during a scramble, but the officials ruled that the whistle had been blown before the puck crossed the line.
Minnesota sealed the game with Brunette's empty-netter with 49 seconds left.
NOTES: The teams will finish their seasons Sunday. The Wild host Dallas, while the Oilers are in Colorado. ... Minnesota completed a season series sweep. ... Eberle locked up the Oilers scoring title with his 43rd point of the season, surpassing Taylor Hall, Ales Hemsky and Sam Gagner, who are all injured for the rest of the season. ... The Oilers held a pregame ceremony for retiring singer Paul Lorieau, the primary anthem singer at Edmonton home games since 1981.


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Danone's Light & Free Berry Smoothie Bowl
- By Rachel Tran
- 12 May, 2016
- 1 Comment
Now that summer's here in London there's nothing more refreshing than a fruity smoothie after a workout. We love the tanginess of mixed berries and the icy, silky texture. Plus, … Continue Reading →
Food and Lycra | 3rd Birthday
- By Laura Lakam
- 27 February, 2016
- No Comments
Hey guess who's back! It's been a hot minute since we wrote something on our .com. Excuse our silence guys. Life has been on the way. This month we are … Continue Reading →
Beats 1 Run LDN
- By Kim Ngo
- 30 October, 2015
- 1 Comment
You probably already know we love a good run, especially in different countries and most importantly followed by good food. So when we were invited along to run the Beats … Continue Reading →
Recharge with SmartWater – Nike Women's 10km London
- By Rachel Tran
- 6 August, 2015
- No Comments
One month, two 10km's and a load of 'life' later and we finally have time to update Food & Lycra with our latest antics! For the third year in a … Continue Reading →
Earl grey waffle with Vonshef waffle maker
- By Laura Lakam
- 20 May, 2015
- 1 Comment
Waffles are quite traditional, and very basic to make. Wherever you go to get a waffle, you'll always get a plain one with a topping or more of your choice. … Continue Reading →
'Food & Lycra' x 'This Girl Can' runs The British 10km
- By Kim Ngo
- 22 March, 2015
- No Comments
This Girl Can, the campaign that 'celebrates the women who are doing their thing no matter how they do it, how they look or even how sweaty they get. Filling … Continue Reading →
Sony Run Your Way | Our City Lights Run with Time Out London
- By Laura Lakam
- 17 March, 2015
- No Comments
Last month we found out we were going to be one of the three official bloggers for the Time Out London and Sony Xperia #SonyRunYourWay events! Not only did we … Continue Reading →
Beats Hours of Power: Beats by Dre Powerbeats2 Wireless presents Barry's Bootcamp
- By Rachel Tran
- 12 February, 2015
- No Comments
We are so fortunate to have so many friends who share the love of food and fitness as much as we do. If there is an opportunity for us to … Continue Reading →
Forever 21 Activewear – Cook Together, Eat Together
- By Kim Ngo
- 16 January, 2015
- No Comments
After a long run or a tough workout the first thing to make noise would be our bellies! And boy do they rumble! A quick freshen up, change of gear … Continue Reading →
Forever 21 Activewear – Train Together, Sweat Together
- By Laura Lakam
- 14 January, 2015
- No Comments
Happy New Year, guys! It's the middle of January already, where does the time go? This time last year, we were in the midst of training for a MARATHON. So … Continue Reading →


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Drafting Workplace Social Media Policies: Address Smartphones, Apps & More
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Powerful PowerPoint Presentations for Lawyers: How to Impress in Court
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Strategies from a Powerhouse Female Lawyer: Shattering the Old Boys' Mold
November 4, 2016
Records Retention Policies: Compliant Retention, Storage and Destruction
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Don't Hit Send! How to Help Clients Avoid Unintended Email Contracts
October 5, 2016
Online Marketing for Lawyers: Inbound and Social Media
August 22, 2016
Clients From Hell: Ethical Concerns When Terminating Client Relationships
July 20, 2016
Power Writing for Lawyers: Simple Strategies to Make Every Word Count
June 21, 2016
Running Social Media & Online Contests: What's Legal, What's Not
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Protect Against Metadata Danger: What's Lurking in Your Digital Documents
December 16, 2015
Effective PowerPoint Techniques for Lawyers: Creating Presentations with Impact
December 15, 2015
Record Retention Policies: Compliant Retention, Storage and Destruction
November 18, 2015
Alternative Careers for Lawyers: How to Leave the Practice of Law
September 17, 2015
Legal Ethics in the Era of Social-Media, BYOD, "The Cloud" & eDiscovery
July 15, 2015
Out-of-Control Client Rates You Online: Ethical Ways to Save Your Reputation
June 17, 2015
Restrictive Covenants: Protect Your Data & People from Unfair Competition
June 11, 2015
Bitcoins But BIG Legal Issues: The New Frontier of Virtual Currencies
May 14, 2015
Metadata for Lawyers: Cover Your Trail When Creating Electronic Documents
May 11, 2015
Understanding Financial Statements: Accounting & Reporting Issues for Lawyers
April 14, 2015
Legal and Binding E-Contracts: What Works in a Digital World
March 17, 2015
Drafting and Negotiating Restaurant Leases: Key Clauses and Provisions
February 17, 2015
Drafting & Negotiating M&A Contracts: Best Practices & Pitfalls to Consider
January 22, 2015
Antitrust Scrutiny: Ways to Plan, Prepare and Respond
December 17, 2014
Navigating Government Contract Bid Protests: Keys to Process and Litigate
December 16, 2014
Drafting Shareholder Agreements: Best Practices and Potential Pitfalls
December 15, 2014
Structuring Alternative Fee Arrangements: What Works, What Doesn't
November 13, 2014
Drafting Complex Indemnification Clauses: Keys to Create Airtight Provisions
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Excel for Lawyers: Create Better Worksheets in Less Time
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Legal Risks in Cloud Computing: Keys to Navigating the Storm
September 12, 2014
Record Retention Policies: Compliant Retention, Storage and Destruction
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Effective PowerPoint Presentations for Lawyers In & Out of the Courtroom
August 26, 2014
Keeping up with TCPA: Avoid Liability with Mobile Marketing
August 6, 2014
Drafting Effective Buy-Sell Agreements: Proven Strategies that Work
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Ethics for Lawyers: Using Twitter & LinkedIn for Legal Marketing
June 24, 2014
Legal and Binding E-Contracts: What Works in a Digital World
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Drafting Precise Contingency Clauses: Avoid Pitfalls and Mitigate Risks
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Properly Drafting Preliminary Agreements: Avoid Breaches & Unwanted Litigation
March 10, 2014
Boilerplate Standard Clauses: Overlooked, Underappreciated and Dangerous
February 13, 2014
Facebook, Twitter & Social Media: Do's & Don'ts for Legal Investigations
February 12, 2014
Public Speaking for Lawyers: Powerful & Proven Techniques (Video Webinar)
January 16, 2014
Drafting Operating Agreements for LLCs: Keys to Structure and Customize
December 11, 2013
Drafting Service Level Agreements: Reduce Risk of Service Level Failures
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Strategies for Drafting Concrete Indemnification Provisions
October 17, 2013
Defending Rule (b) (6) Corporate Depositions: Key Strategies for Success
October 10, 2013
Record Retention Policies: Compliant Retention, Storage & Destruction
September 10, 2013
Mobile Devices & The Law: Privacy, Security, E-Discovery, and Privilege
August 7, 2013
Keys to Drafting and Negotiating Effective Acquisition Agreements
August 7, 2013
Independent Contractor Agreements: Keys to Draft, Negotiate and Review
July 10, 2013
A Practical Guide to Reviewing and Negotiating Franchise Agreements
June 13, 2013
How to Use Facebook, Twitter & Social Media For Legal Investigations
May 14, 2013
Working With Consultants: What's Privileged, What's Not?
May 13, 2013
Value Based Fee Arrangements: What Does and Doesn't Work
April 25, 2013
SharePoint 2013 Legal Essentials: Keys For E-Discover and Data Storage
April 11, 2013
Understanding and Interpreting Financial Statements for Lawyers
March 27, 2013
Drafting Complex Indemnification Provisions: Keys To Surviving The Traps
March 21, 2013
Ethics and Professional Responsibility for DC, MD & VA Corporate Lawyers
February 20, 2013
Legal and Binding E-Contracts: What Works in a Digital World
February 14, 2013
Legal Risks in Cloud Computing: Keys to Navigating the Storm
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Get Your Electronic Evidence Admitted in Court: Steps Towards Authentication
January 9, 2013
Public Speaking for Lawyers: Powerful & Proven Techniques (Video Conference)
January 9, 2013
Prevent Breach of Contract: Lessons Learned From Litigating the Mistakes
November 6, 2012
Pinterest & Intellectual Property: Reduce Risk & Protect Your Clients
November 1, 2012
Drafting Power Purchase Agreements: Updates for Renewable Energy Projects
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Drafting Indemnification Clauses: Best Practices and Potential Pitfalls
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Record Retention Policies: Compliant Retention, Storage & Destruction
September 6, 2012
Demystifying Conflicts of Interest: Dangers Attorneys Need to Know
August 7, 2012
Be a Social Media Rainmaker: Strategies for Facebook, LinkedIn & Twitter
August 1, 2012
Conducting Internal Investigations: What Lawyers Need to Know
July 11, 2012
Social Media & E-Discovery: What Every Lawyer Should Know
July 2, 2012
Drafting Engagement Letters: Avoid Common Pitfalls of Representation Issues - Ethics CLE
June 5, 2012
Protecting Privilege & Work Product When Working With Consulting Experts - Ethics CLE
April 11, 2012
Legal and Binding E-Contracts: What Works in a Digital World
March 15, 2012
Legal Risks in Cloud Computing: Keys to Navigating the Storm
March 13, 2012
How to Use Facebook, Google+ & Social Media for Legal Investigations
February 15, 2012
Drafting Indemnification Clauses: Best Practices and Potential Pitfalls
February 9, 2012
Fracking Under Pressure: Crucial Litigation Tactics You Need to Know
January 12, 2012
Effective E-discovery When the Government is a Party
January 10, 2012
Drafting an Effective Arbitration Clause: It's Not One Size Fits All
December 8, 2011
International E-Discovery: How to Effectively Collect ESI
November 15, 2011
Record Retention Policies: Compliant Retention, Storage & Destruction
November 10, 2011
Strategies for Drafting Concrete Indemnification Provisions
October 26, 2011
Analyzing Financial Statements: What Every Attorney Should Know
October 5, 2011
Effective Habits of Successful Rainmakers: Proven Strategies That Work
August 18, 2011
Renewable Energy Projects: Legal Strategies for Siting & Permitting
August 11, 2011
Preventing Retaliation Claims: Cat's Paw, Title VII & Third-Party Protection
August 10, 2011
SCOTUS Annual Term Update: Recent Decisions You Need To Know
August 9, 2011
Boilerplate Standard Clauses: Overlooked, Underappreciated and Dangerous
August 4, 2011
Mobile Devices and the Law: Legal Issues with Privacy, Security and eDiscovery
July 20, 2011
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A fund that provides an opportunity to save tax while growing your money through Equity investments.
Mutual Fund investments are subject to market risks, read all scheme related documents carefully.
Mutual Fund investments are subject to market risks, read all scheme related documents carefully.
Atleast 80% in equity, and equity linked instruments. Upto 20% in short term, money market & liquid instrument.
The Scheme would adopt bottom-up approach of investing. An investment approach whereby the Fund will search for individual stocks that are performing well. This approach assumes that individual corporations can do well even though its industry is not doing well. The investment emphasis of the Scheme will be in identifying companies with strong competitive position in good businesses, and having quality managements. Essentially focusing on long term fundamentally driven values. The fixed income investment strategy would emphasise investment in instruments that generate consistently superior yields at low levels of risk.
*In terms of SEBI circular no. SEBI/IMD/CIR No.4/ 168230/09 dated June 30, 2009,
no entry load will be charged by the Scheme to the investor effective August 1,
2009. Upfront commission shall be paid directly by the investor to the AMFI registered
Distributors based on the investors' assessment of various factors including the
service rendered by the distributor.
Additional Products
Entry Load : As applicable to the scheme. Exit Load : As applicable to the scheme.
Exit Load at time of transfer out of Debt Scheme: Nil. Entry Load at time of transfer into Equity Scheme: Entry Load as applicable to respective Scheme. Exit Load at time of redemption / repurchase: Exit Load as applicable to respective scheme.
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We stayed at the Villa Le Maschere and enjoyed the peace and beautiful surroundings. The swimming pool in particular offers warm water that does not irritate your eyes. The rich breakfast at the terrace outside with views over the valley was also very enjoyable.
We however have to mention one negative point: food prices are too high for the quality that is offered, which applies for both the dinner possibilities (which is good but not special) as for the pool bar service (example pool bar prices: ice cream 12€, beer 7€, sandwich 12€, Cola 5€, Mojito 15€, ...). People visiting this hotel can afford it, but it does not feel right.
Bring walking shoes if you are interested in a short hike in the bushy and beautiful domain (paths are not well maintained).
- Official Description (provided by the hotel):
- A revival of tradition with a contemporary twist and refined settings where perfect harmony exists between history,art and design.architectural features, interiors and exteriors restored to their former splendor, are witness to the evolution of tradition and development of style and techniques that all go to make up the history of villa le maschere. Splendid frescoes and ornamental stuccos that are true works of art, render every room unique. ... more less
- Reservation Options:
- TripAdvisor is proud to partner with Orbitz, Expedia, Travelocity, Hotels.com, Priceline, Booking.com, TripOnline SA, Cheap Tickets, Hotwire, HotelQuickly and HRS so you can book your Villa Le Maschere reservations with confidence. We help millions of travelers each month to find the perfect hotel for both vacation and business trips, always with the best discounts and special offers.
- Also Known As:
- Villa Le Maschere Hotel Barberino Di Mugello
- Hotel Le Maschere
- Resort Le Maschere
- Villa Le Maschere Tuscany, Italy


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Diarrhea Planet - Turn to Gold$15.99
At long last! The face-melting, highly-anticipated, larger-than-life third album by Diarrhea Planet. Recorded and produced by Vance Powell (JEFF The Brotherhood, Jack White, PUJOL), Turn To Gold takes the joyous energy of Diarrhea Planet's live show and pushes it through your eardrums straight to your heart. Turn To Gold is out June 10th, but you can preorder special packages with sick limited edition "turning to gold" vinyl starting... now!


text: august, 2014 24aug10:00 am- 4:00 amExcellence In Education Home Tour Time(Sunday) 10:00 am - 4:00 am Event DetailsSunday, August 24th 10:00 a.m. – more Event Details Sunday, August 24th 10:00 a.m. – 4:00 p.m. $40 per person in advance, $50 per person at the door Presented by the Tahoe Sierra Board of Realtors, the 6th annual Excellence in Education Home Tour returns with another stunning collection of mountain homes. From architecture to interior design to landscaping, this year's homes showcase the best of mountain modern architecture and lifestyle. Enjoy live music and light refreshments at the Park Pavilion following the tour. Proceeds from ticket sales benefit the Tahoe Truckee Excellence in Education Foundation and the MCCF. Home Tour tickets may be purchased at the Martis Camp Sales Office or online at www.exined.org. For more information, contact Marketing Manager Heather Morgan at (530) 550-3200 or email@example.com. Calendar GoogleCal No Comments Sorry, the comment form is closed at this time.


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|Program Name Change for B.A from Classical Civilization to Classical Studies
|Submitting Dean
|Dean Roger Creel
|Submitting College
|Arts & Sciences -- Charles Monroe x8033
|Departments Generating the Proposal
|Objection Deadline
|February 10, 2003
|Proposal Status
|Final Approval Granted
|Proposal Last Updated
|March 13, 2003 by PR Nancy Stokes
|Effective Date
|Fall 2003
|Brief Summary of Proposal
|The program change streamlines offerings in an interdisciplinary package which strengthens enrollments and makes economical use of faculty time. It emphasizes the strengths of UA in contrast to a more traditional language-based program at KSU. As an interdisciplinary major the 100- and 200-level courses provided a foundation in the multiple methodologies and the breadth that involves courses from other departments. Depth is provided in the required 21 hours of 300-400 level courses in Archaeology, Classical Studies, History, and Philosophy. The college requirement for 47 credits in 300-level or above courses will encourage students to take additional courses from the nine upper division courses noted under electives. 7100:100 Art History I provides an introduction to the methodology of art history and covers ancient art. 3230:150 Cultural Anthropology provides the foundation for a cross-cultural perspective and provides a theoretical foundation for advanced archaeological courses. 3200:220 Introduction to the Ancient World surveys the cultural achievements of the ancient world and essential methodology. 3200:230 Sports and Society in Ancient Greece and Rome provides a first encounter with cross-cultural analysis. 3200:289 Mythology of Ancient Greece provides students with the fundamental "language" of ancient literature and thought. 3600:211 History of Ancient Philosophy provides essential background to the development of Greek philosophy before Aristotle.
|Type of Proposal
|Program changes
|Graduate School Endorsement Status
|Not required
|Graduate School Endorsement Updated
|November 18, 2002 by GS Heather Blake
|Institutional Research Status
|IR Status Updated
|January 27, 2003 by IR Dolores Bezilla
|Library Status
|Library Status Updated
|October 31, 2002 by UL Diana Chlebek
|Distance Learning Review Committee Status
|Not required
|DLRC Status Updated
|Resource Requirements
|No additional resources
|Resource Requirements Updated
CPS Menu


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Pawprint Pinches
$ 83.99
Beautifully sculpted renditions of various animals paw prints. Pinchable! Kids love these holds not only because they look cool but also because they're easy to hold onto, and friendly to their tender little tendons. Experienced climbers will like them for the same reasons. These are good for a 5.8 and up on a vertical wall.
...sculpted by Terry Moeller
...sculpted by Terry Moeller
- 8 holds
- pictured here in light purple with a matching SoftBack
- SoftBack recommended


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text: SEOUL, South Korea ( TheStreet) -- Samsung Electronics filed a complaint with the U.S. International Trade Commission that seeks to ban Apple's ( AAPL) importation and sale of iPhone, iPad and iPod devices in the U.S. Samsung said in a statement that Apple infringes on five of the South Korean electronics company's patents. Samsung said it is seeking a "permanent exclusion order prohibiting entry to the United States of all Apple products in violation of these patents." Apple assembles many of its products outside the United States. Samsung's complaint ratchets up the fight between the two technology giants. Just last week, Apple filed a lawsuit in South Korea against Samsung alleging Samsung has infringed patents on smartphones and tablet computers. Apple also sued Samsung in the U.S. in April alleging Samsung's Galaxy-branded cellphones and tablets copy the iPhone and iPad. Samsung fired back, suing Apple in South Korea, the U.S. and elsewhere for alleged patent rights violations. -- Written by Joseph Woelfel >To contact the writer of this article, click here: Joseph Woelfel >To submit a news tip, send an email to: email@example.com.


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Question about 1996 Cadillac DeVille
I noticed that the left rear tail light was out so i changed the burnt out bulb. A couple days later I noticed that it was out again but the bulb was fine. I checked all the fuses but cant find a problem. The turn signals seem to blink quicker than usual as well. Where would be a good place to start looking for a problem.
Posted by s_satter on
Ok, I tried both and nothing for either. There is something else that I noticed. When I push the Lock/Unlock button on the remote ONLY the right side lights up..but when i put my left blinker or brake on..the left lights up fine. could there be a bad relay or something somewhere? The small bulb doesnt ever work at all.
Check to see if the yellow wire is broken at the connection right below the lights. I just had to repair broken wires on both sides where they had broken off at the connections
Posted on Oct 03, 2009
If you have access to a simple 12 volt test light, you can remove the bulb you replaced, turn on the turn signal and park lights and see if the test light lights up. If the turn signal contact blinks the test light and the tail contact lights the test light, you know your power supply to the bulb is good.
Next you will check the ground.
Using your test light, carefully touch the tail light contact with the test light tip and touch the test light ground to the socket ground. If the ground is good the test light should light.
Let me know what you find and we will go from there.
Posted on Feb 17, 2009
SOURCE: I have freestanding Series 8 dishwasher. Lately during the filling cycle water hammer is occurring. How can this be resolved
a 6ya expert can help you resolve that issue over the phone in a minute or two.
best thing about this new service is that you are never placed on hold and get to talk to real repairmen in the US.
the service is completely free and covers almost anything you can think of (from cars to computers, handyman, and even drones).
click here to download the app (for users in the US for now) and get all the help you need.
Posted on Jan 02, 2017
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Model Mayhem Admin
JoJoHModel Female Vancouver, British Columbia, Canada
Mayhem # 261020
About Me
Hi, first off my name is Joe Joe.
I've always been interested in modeling but i haven't looked into it yet till now and i want to get something started. I'm 20 years old currently living in Vancouver. I'm just looking here to see how i can get this started. I'm new to this whole model industry. I'm 5ft 6inches I'm chinese, body type is avg. I'm open to new things.
If you have any suggestions or jobs offers then feel free to leave me a message you can contact me by email firstname.lastname@example.com or you can leave me a msg here. Thanks once again. Hope to hear from you guys
*** NO nudity involved please *** thanks for taking your time
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A weak and tormented teacher is pushed to the limit by his obnoxious students.
Ole Børud (born December 6, 1976) is a Norwegian singer, songwriter and instrumentalist, known both for his solo recordings and as a member of the band Extol. Børud, son of Norwegian gospel singer Arnold Børud, began performing music at age five as part of Arnold B. Family. He later started playing in hard rock and heavy metal bands, first in the two-man project Schaliach and later for Extol and, briefly, the hardcore punk band Selfmindead. Since the early 2000s, he has also recorded several solo albums featuring pop, funk, and jazz styles. In 2016, he formed a heavy metal side-project, Fleshkiller, with his former Schaliach band-mate, Peter Dalbackk, and drummer Andreas Skorpe Sjøen.
On Silence Yourself, Savages' passion burned so brightly it seemed like it might consume itself before they could record a second album. Fortunately, Adore Life proves that the band not only has the endurance to return, but the finesse to come back better than ever. Jehnny Beth and company sound as bold as they did on their debut, but with a newfound precision that only makes their impact more powerful. Adore Life depicts love's most fearsome and joyous sides with a hunger that feels like these songs are really about devouring and being devoured. The churning opener "The Answer" boils relationships down to the plainest ultimatum possible: "If you don't love me/Don't love anybody."


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CUSTOM WOOD PRINT - Large
or make 4 interest-free payments of $55.00 fortnightly with More info
455mm x 605mm (18" x 24")
A brand new way to showcase your captured moments!
Offering the unique opportunity to print your own photos on wood, this product preserves your images in an innovative way that's both captivating and creative.
Simply upload your favorite digital images, and we will print them directly onto beautiful birch plywood. The result is a quality image, that is scratch and water resistant, has uninterrupted depth, and is a keepsake to last forever.
Your wood prints are carefully packaged and sent to you with Australia Post tracking, ready to give as the perfect gift or keep for yourself for your home or office.
Prints measure 12mm deep. They come ready to mount on the wall - with a routered notch to be hung on a wall hook. Alternatively, these will display well using quality 3M mounting tape.
Uploading your images:
- Strictly ONE IMAGE uploaded per wood print purchase.
- Please limit the file size to 10MB. (Jpeg and Tiff files are preferred).
- The best file format to send to us is a high resolution jpg - a minimum of 300dpi is recommend.
Images printed in this way look best with light coloured photos (for example: open skies or white/light backgrounds). The less ink that is used, the more the natural wood will show through and showcase this unique printing method. Please keep this in mind when selecting your photos to print.
Due to the nature of this product, no two prints are exactly the same, and each printed timber panel has its own natural grain. Also, we purposefully do not use any white ink, so anything white in your photo will actually be the natural light wood colour showing through.
Please read our shipping advice before placing your order.
* Arlo and Co respects the intellectual property of others, and we ask our users to do the same. Therefore, in your use of and interactions with our website, you may not modify, distribute, or reproduce in any way any image that is copyrighted material belonging to others, without obtaining their prior written consent. Please refer to our Terms of Use. Please inform us via email if you would prefer not to have your product on social media.


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