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Gastroesophageal reflux in anesthetized dogs: a review¤
Reflujo gastroesofágico en perros anestesiados: revisión de literatura
Refluxo gastroesofágico em cães anestesiados: revisão de literatura
Carlos A Rodríguez-Alarcón1, DVM, PhD; Diana M Beristain-Ruiz1*, DVM, PhD; Ramón Rivera-Barreno1, DVM, MSc, PhD; Guadalupe Díaz2, DVM; Jesús M Usón-Casaús3, DVM, PhD; Ricardo García-Herrera4, DVM, PhD; Eva M Pérez-Merino3, DVM, PhD.
1 Cuerpo Académico de Medicina y Cirugía Veterinaria, Departamento de Ciencias Veterinarias, Universidad Autónoma de Ciudad Juárez, Anillo Envolvente del PRONAF y Estocolmo S/N. Ciudad Juárez, Chihuahua, México.
2Hospital Veterinario Universitario, Universidad Autónoma de Ciudad Juárez, Anillo Envolvente del PRONAF y Estocolmo S/N. Ciudad Juárez, Chihuahua, México
3Hospital Clínico Veterinario, Facultad de Veterinaria, Universidad de Extremadura, Av. Universidad S/N. Cáceres, España.
4División Académica de Ciencias Agropecuarias, Universidad Juárez Autónoma de Tabasco. Zona de la Cultura S/N, Villahermosa, Tabasco, México.
*Corresponding Author: Diana M Beristain Ruiz. Departamento de Ciencias Veterinarias, Universidad Autónoma de Ciudad Juárez, Chihuahua, México. Email: firstname.lastname@example.org
Received: March 21, 2013; accepted: July 22, 2014 doi: 10.17533/udea.rccp.v28n2a03.
Gastroesophageal reflux can be a catastrophic illness in small animals during anesthesia since its complications can cause serious pathologies, such as esophagitis, esophageal stenosis and aspiration pneumonia. With an incidence from 12 to 78.5% in anesthetized dogs, gastroesophageal reflux is normally silent during anesthesia and will be notices only if regurgitation occurs and stomach acid is present in the nasal or oral cavities. In humans, gastroesophageal reflux disease (GERD) is a well-defined pathology where the lower esophageal sphincter has a sustained weakness. However, in dogs, gastroesophageal reflux disease as such is not well established, if at all; it has only been described as gastroesophagic reflux, occurring principally in anesthetized animals. There are several factors influencing the presentation of reflux in anesthetized dogs, which may be inherent to the patient (e.g. age, sex, breed, weight, or body condition), medications used prior to and during anesthesia, type of surgery or position of the animal during surgery. The objective of this review is to discuss a series of conditions that could predispose dogs to gastroesophageal reflux during anesthesia and to assist in the prevention and diagnosis of this condition.
Keywords: anesthesia, aspiration pneumonia, canine, esophagitis.
El reflujo gastroesofágico durante la anestesia puede ser una entidad catastrófica en la clínica de pequeñas especies, ya que sus complicaciones derivan en entidades realmente graves como esofagitis, estenosis esofágica y neumonía por aspiración. Con una incidencia del 12 al 78.5% en perros anestesiados, el reflujo gastroesofágico durante la anestesia es generalmente silencioso y sólo se observa cuando existe regurgitación y el reflujo pasa a cavidad oral o nasal. En el humano, la enfermedad por reflujo gastroesofágico (ERGE) es una patología bien definida, donde el esfínter esofágico inferior presenta una debilidad sostenida. Sin embargo, en el perro esta enfermedad como tal no está bien establecida, si acaso se describe el reflujo gastroesofágico, que ocurre principalmente en animales anestesiados. Existen diversos factores que influyen en la presentación del reflujo en los perros anestesiados. Estos pueden ser inherentes al paciente (por ejemplo: edad, sexo, raza, peso o condición corporal), a medicamentos utilizados previamente y durante la anestesia, al tipo de cirugía o a la posición del animal durante la cirugía. El objetivo de esta revisión es discutir una guía de las condiciones que predisponen a la aparición de reflujo gastroesofágico durante la anestesia en perros con el fin de facilitar el diagnóstico y la prevención de esta condición.
Palabras clave: anestesia, canino, esofagitis, neumonía por aspiración.
O refluxo gastroesofágico durante a anestesia pode ser uma entidade catastrófica na clínica de pequenas espécies, já que suas complicações resultam em entidades realmente graves, como esofagite, estenose esofágica e pneumonia por aspiração. O refluxo gastroesofágico em cães anestesiados é geralmente silencioso, com uma incidência de 12 até 78.5% e só é observada quando há regurgitação e o refluxo passa até a cavidade oral ou nasal. Nos humanos, a doença pelo refluxo gastroesofágico (ERGE) é uma patologia bem definida, onde o esfíncter esofágico inferior apresenta uma debilidade continua. Porém, esta doença em cães não está bem estabelecida, pelo qual só se descreve o refluxo gastroesofágico, que ocorre principalmente em animais anestesiados. Existem diversos fatores que influenciam na apresentação do refluxo em cães anestesiados. Estes podem ser inerentes ao paciente (por exemplo: idade, sexo, raça, peso ou condição corporal), a medicamentos utilizados previamente e durante a anestesia, ao tipo de cirurgia ou a posição do animal durante a cirurgia. O objetivo da revisão foi discutir uma guia das condições que predispõem à aparição de refluxo gastroesofágico durante a anestesia em cães com o fim de facilitar o diagnóstico e a prevenção dessa condição.
Palavras chave: anestesia, cão, esofagite, pneumonia por aspiração.
Gastroesophageal reflux in dogs
In dogs, esophagitis can be caused by a variety of reasons, such as ingestion of caustic substances (including prescribed medications), chronic vomiting, muscular diseases, improper placement of feeding tubes, tumors, or gastroesophagic reflux (GER; Willard, 2004). Hiatal hernias cause GER in some breeds, such the Shar-Pei, however, anesthesia is the most common, worrisome and probably thoroughly studied cause of GER in dogs (Willard, 2004; Glazer and Walter, 2008). Most of the drugs used during anesthesia, such as pre-anesthetics (sedatives or tranquilizers) or anesthetics have the ability to relax the lower esophageal sphincter (LES), allowing the passage of gastric contents into the esophagus (Wilson et al., 2005; Wilson et al., 2006; Wilson et al., 2007).
In animals, primary gastroesophageal reflux disease (GERD) has been reported in cats (Han et al., 2003); however, it is not well established in dogs. Some of the characteristics of the etiology, pathophysiology, and treatments of GERD in humans can be applied to GER during anesthesia in dogs. The anatomy, defense mechanisms and relaxation factors of the LES serve as a basis to the understanding of GER during anesthesia, which is why we will discuss some aspects of human GERD in this review (Jergens, 2004; Vlasin et al., 2004).
The LES plays an important role in the anatomy of the digestive tract, preventing gastroesophageal reflux. There are various correlated factors that allow the LES to work efficiently as an anti-reflux barrier (Miller et al., 2009; Hyun and Bak, 2011); a) muscle layers around the esophagus and diaphragmatic crura; b) the acute angle formed at the union between the esophagus and the cardia of the stomach (a flap valve); c) the closure produced by the esophageal mucosal folds when the esophagus is collapsed; and d) the intra-abdominal portion of the esophagus.
Any alteration in these mechanisms will cause reflux in dogs, subsequently producing damage in the esophageal mucosa and causing esophagitis. The damage to the esophageal mucosa can be attributed to the prolonged contact with gastric acid, pepsin, bile salts, and trypsin. Chronic esophagitis can cause esophageal stenosis due to damage of the submucosa and muscular layers, which form an intraluminal fibrosis that causes scarring (Gualtieri, 2005). In general, it is assumed that GER precedes esophagitis, though other factors must be considered since not all dogs with GER will necessarily develop esophagitis (Wilson and Walshaw, 2004). The factors that determine the development of esophagitis after an episode of GER in small animals are similar to those found in humans: a) incompetence of the antireflux system; b) acidity and type of enzymes present in the gastric content in contact with the mucosa; c) self cleaning ability of the esophagus; and d) resistance of the esophageal mucosa. However, such factors studied in humans are not well defined in domestic animals (Pratschke et al., 1998). The pH of the gastric content, along with the length of time that it was in contact with the mucosa can be a triggering factor for esophagitis. In dogs, it has been demonstrated that a pH of less than 2.5 sustained for 20 minutes or more is capable of producing severe damage to the esophageal mucosa (Wilson and Walshaw, 2004).
Gastroesophageal reflux during anesthesia
During anesthesia, GER (Figure 1) occurs when the reflux pH falls below 4.0 (gastric acid reflux) or increases above 7.5 (bile reflux) for 30 seconds or more (Wilson et al., 2005). GER during anesthesia has been correlated with various factors, including the type of surgery, patient position and the pre-anesthetic and anesthetic drugs administered. There have also been studies regarding how to prevent GER during anesthesia in small animals (Strombeck and Harrold, 1985; Roush et al., 1990; Galatos and Raptopoulos, 1995a, 1995b; Raptopoulus and Galatos, 1997; Chacon, 1998; Raptopoulus and Savvas, 2004; Rodríguez, 2010). Also, during anesthesia there is a reduction of peristalsis and a lack of saliva that neutralizes acid pH, contributing to the development of esophagitis (Jergens, 2004).
It is possible that animals presenting GER during anesthesia had an existing problem of the cardia, predisposing them to reflux, especially with the use of medications that relax the LES (Vlasin et al., 2004). In order for GER to occur in dogs, three defense components must fail: a) an external mechanism formed by the diaphragmatic crura that wraps like a sling around the abdominal esophagus augments sphincteric pressure during inspiration; b) an internal mechanism constituted by the intrinsic muscle of the distal portion of the esophageal wall; and c) the circular muscle fibers of the stomach. The internal component of the esophagus is considered the first line of defense against gastric reflux. When intragastric pressure exceeds the internal components of the LES, the external components take over, providing the next level of protection (Brasseur et al., 2007).
Influence of the type of surgery on GER in anesthetized dogs
It is difficult to establish which type of surgery causes more reflux during anesthesia. It has been found that abdominal surgeries predispose to a higher incidence of reflux because of an increase in the intra-abdominal pressure. Uterine surgery, on the other hand, is described as the most common cause of GER in dogs (Galatos and Raptopoulos, 1995b). Recent findings showed that gastrointestinal surgery, diagnostic imaging procedures, or a combination of both during the same anesthetic procedure increase the risk of regurgitation. It is possible that a change in the depth of the anesthesia, patient handling, and changes in body position may cause GER (García et al., 2013). However, another study has shown that GER occurred in 13% of anesthetized dogs, none of which had undergone abdominal surgery (Rodríguez, 2010). It is also described that placing the dog in the Trendelenburg position (head down) predisposes to reflux. This position is used when the viscera requires cranial movement. Patients that have undergone previous surgery also show a higher incidence of GER (Galatos and Raptopoulos, 1995a,b). Other studies have reported that dogs that undergo orthopedic surgery have a higher risk of presenting GER during anesthesia (Rodríguez, 2010, Lamata et al., 2012).
Influence of sex on GER in anesthetized dogs
It could be possible that the high number of females with GER during surgery of the reproductive system is due to the high number of interventions performed in small animal clinics, but other factors must be considered. For example, in humans, it is the elevation of progesterone and not the pressure of the fetus that causes reflux in pregnant women. In the same way it has been described that in female dogs progesterone and estrogen cause the LES to relax, which predisposes to reflux (Nilsson et al., 2003). Another study showed that postoperative benign esophageal stricture developed in hysterectomized dogs should probably not be attributed to the effects of increased concentrations of female sex steroid hormones. In that study, animals were evaluated under the influence of different concentrations of endogenous progesterone and estradiol-concentrations, and were premedicated with acepromazine and thiopental and maintained with halothane. Lower esophageal pH was monitored continuously for 1 hour after induction, and GER was detected in only one animal (Anagnostou et al., 2009). In another recent study on anesthetized dogs, none of the dogs with GER had undergone an ovariohysterectomy, concluding that neither gender, nor hormones, was an important factor in the predisposition to GER during anesthesia (Rodríguez, 2010).
Influence of breed, body condition, and age on GER during anesthesia
Among all dog breeds, it has been found that Poodles commonly present this problem (Wilson et al., 2004, Rodríguez, 2010). Another study reported that Labrador Retrievers and German Shepherds presented more reflux during anesthesia than controls (Lamata et al., 2012).
A relationship between chronic obstructive respiratory syndrome and GER has been observed in dogs (Lecoindre and Richard, 2004; Poncet et al., 2005). This is possibly because an anomalous inspiratory effort might induce an abnormally low negative intrathoracic pressure that could worsen or even induce GER. Endoscopic examination of the upper digestive tract in 30 dogs with chronic obstructive respiratory syndrome showed that 25 of these dogs presented reflux esophagitis in different stages (Lecoindre and Richard, 2004). However, brachycephalic dogs predisposed to chronic obstructive respiratory syndrome are not predisposed to GER during anesthesia.
A study showed that the abdominal esophagus has different lengths depending on the breed (Pratschke, 2004). In that study, the esophagus in most of the Greyhounds and Beagles was contained entirely within the thoracic cavity such that no portion of the esophagus could be subject to abdominal pressure, which is likely associated with GERD (Pratschke et al., 2004). If this is true, then it could be possible that Poodles, Labrador Retrievers and German Shepherds also have a short abdominal esophagus, predisposing them to reflux, though this has not been proven. The position and segment of the terminal esophagus within the abdominal cavity in dogs are very important. This portion of abdominal esophagus acts as a reflux barrier according to the law of LaPlace. This law stipulates that the pressure inside a hollow viscus is inversely proportional to its radius. The esophageal radius is consistently shorter than the gastric radius. Consequently, when both are exposed simultaneously to the positive intra abdominal pressure, the pressure within the segment of abdominal esophagus always exceeds the internal gastric pressure, which helps prevent GER (Pratschke et al., 2004). It has been documented that dogs regurgitate as a normal physiological event (Patrikios et al., 1986). Interestingly, in this species a consistent and identifiable abdominal esophagus has not been documented. In contrast, the rat, a species with a separation of the high pressure anti-reflux barrier in two distinct regions with a clear abdominal esophagus (Soto et al., 1997), does not have the ability to vomit and the phenomenon of GER has not been observed in this species (Pratschke et al., 2004). To elucidate this higher predisposition to GER during anesthesia, additional studies similar to that of Pratschke’s should be conducted to address the conformation of LES in other breeds.
One study showed that there was no significant association between GER and body weight (Wilson et al., 2005). In addition, other research showed that 76.92% of the patients that presented GER during anesthesia had a normal body condition, while 23.08% were underweight and 0% were obese; there was an increase of GER in large breed dogs (33 kg to 49 kg; Rodríguez, 2010). Similarly, another study shows that dogs weighting more than 40 kg are more likely to present passive regurgitation (Lamata et al., 2012). There is very little veterinary literature on this issue; however, there have been studies regarding the role of obesity and the risk of GER in humans during anesthesia (Zacchi et al., 1991; Esquide et al., 2004; Freid, 2005; de Leon et al., 2010). In human anesthesia, it has been proven that the combination of a high intra-abdominal pressure, a high volume of gastric content with a low pH, delayed gastric emptying and a high incidence of hiatal hernias would put an obese patient at higher risk of GER (Zacchi et al., 1991). In addition, anesthetized obese patients are more likely to present Mendelson’s syndrome. This is a chemical pneumonitis characterized by a bronchopulmonary reaction after aspiration of gastric contents during general anesthesia (Kamalipour et al., 2012).
A mechanism called barrier pressure (BrP) assists in avoiding aspiration during anesthesia. The BrP is the difference between LES pressure and gastric pressure. This gradient should always be positive and works as a barrier between the stomach and esophagus (de León et al., 2010). In a study that compared the pressures of the LES and BrP with high-resolution solid-state manometry in obese and non-obese patients, both pressures decreased in both types of patients during induction of anesthesia with remifentanil. In obese patients, the BrP was significantly lower, but it still remained positive in all patients (de León et al., 2010). However, other studies state that the pressure gradient between the stomach and the LES is similar between obese and non-obese patients in different surgical positions (Esquide et al., 2004; Freid, 2005). The low relationship between humans with GER and obesity was proven in a study (n = 44) in which seven obese patients were anesthetized and only one developed GER. GER did, however, develop in five out of 37 non-obese patients (Illing et al., 1992). Even though obesity itself has no influence in the presentation of GER, it does create an intra-abdominal condition that favors reflux when the gastroesophageal barrier is weakened (Zacchi, 1991). A human study of 256 fasted surgical patients found that in comparison to obese patients, lean patients that underwent anesthesia had a larger amount of gastric content with a lower pH (Harter et al., 1998). It has been described that a higher acid stomach content will predispose the patient to reflux and aspiration pneumonitis during anesthesia (Schreiner, 1998; Ng and Smith, 2001). In dogs, Rodríguez (2010) described a high incidence of GER in thinner animals that were anesthetized. Unfortunately, the results of different studies addressing the relation of GER and body condition of dogs are not conclusive. This condition is presented in both lean and obese dogs; however, it seems to be more common in large dogs, regardless of their corporal condition. Therefore, it would be important for future research to establish a correlation between dogs’ body condition, pressure of the LES, development of GER during anesthesia, and GER.
Few studies have correlated the age of anaesthetized patients and the development of GER or aspiration pneumonia in veterinary medicine. In some studies, no correlation was found between an increase in patient age and the risk of GER (Wilson et al., 2005; Lamata et al., 2012; García et al., 2013). Nevertheless, in a study performed in 270 dogs divided randomly in groups according to age (2 to 5 months, 6 months to 9 years, and 10 to 15 years) geriatric canine patients had a higher risk of developing GER during anesthesia and their stomach content was more acidic in the case of reflux (Galatos and Raptopoulos, 1995b). Similarly, Rodríguez (2010) found that the majority of reflux during anesthesia occurred in older dogs. At present, there is no explanation for low gastric pH in dogs or humans; also, previous studies in humans failed to establish significant changes in acid secretion (Pilotto et al., 1994; Franceschi et al., 2009). On the other hand, evidence shows that elderly human patients have an increased pH in the stomach content, but their stomach shows a delay in gastric emptying, which could possibly increase the potential of GER during anesthesia (Livingstone, 2003). However, in human anesthesia, children are considered to have a higher risk of developing GER and aspiration pneumonia during anesthesia (Alvarez y Reyes, 2009). This is because most of them have a liquid stomach content of more than 4 mL/kg at the time of anesthesia, with a pH of less than two, regardless of the fasting interval (Maekawa et al., 1998). In relation to this, a metaanalysis concluded that children who preoperatively fluid fasted for more than six hours benefit in terms of intraoperative gastric volume and pH when compared to children permitted unlimited fluids up to two hours preoperatively (Brady et al., 2009). In veterinary anesthesia, the presence of liquid in the stomach of puppies has not been described. It would be of interest to take measurements of the quantity and pH of liquid stomach content during anesthesia to establish if puppies are more likely to present GER and pneumonia aspiration during anesthesia.
Influence of different drugs on GER in anesthetized dogs
Several pre-anesthetic and anesthetic drugs, such as atropine, diazepam, acepromazine, diazepam, xylazine, morphine, halothane, and isoflurane can lead to GER by decreasing the tone of the LES (Kim et al., 1977; Strombeck and Harrold, 1985; Cox et al., 1988; Hashim and Waterman, 1993; Tournadre et al., 1998; Kohjitani et al., 2003; Epstein and Swirsky, 2009; Tables 1 and 2).
It has been shown that atropine is one of the drugs that reduce the tone of the LES in anesthetized humans, cats and dogs, thereby predisposing them to reflux (Strombeck and Harrold, 1985; Tutian, 2010). In spite of this, atropine—as well as glycopyrrolate— does not lower the pH of the esophagus or the stomach when used as a pre-anesthetic in dogs (Roush et al., 1990). The increase in the possibility of producing GER with atropine during anesthesia was confirmed in two different studies completed in the same veterinary hospital with comparable groups of anesthetized animals, and by similar anesthetic protocol. When atropine was used routinely, GER prevalence was 25% (Chacon, 1998) versus 13% when atropine was not used (Rodríguez, 2010).
In humans, diazepam has the ability to significantly lower LES pressure. In the human LES, diazepam could act as a smooth muscle relaxant since myogenic influences have been implicated in the control of LES pressure (Rushnak and Leevy, 1980). However, although dogs have striated muscle fibers in the muscle layer, Hall et al. (1987) reported that diazepam decreased LES pressure in this species.
Reports on acepromazine and its effect on GER in anesthetized dogs are inconsistent. For example, Lamata et al. (2012) found no association between the administration of acepromazine and the probability of a GER episode occurring. However, García et al. (2013) mentioned that the risk of GER was significantly lower in dogs premedicated with acepromazine in combination with an opioid in comparison to patients administered medetomidine alone. This reduction of GER in anesthetized dogs may occur because acepromazine causes a decrease in BrP compared to other drugs (Hashim and Waterman, 1993).
At present, controversy exists as to whether morphine may relax or increase LES tone. Morphine produces emesis when used as a pre-anesthetic. Vomit alone does not determine the possibility of GER during anesthesia, but it is well documented that morphine, when used as pre-anesthetic, increases the risk of GER (Wilson et al., 2005) since it decreases muscle tone in the LES (Mittal and McCallum, 1986). However, Penagini, and Bianchi (1997) stated that morphine might inhibit the spontaneous relaxation of LES. Another study claims that morphine increases LES pressure when used subcutaneously (Kraichely et al., 2010). A recent study found no association between the use of opioid drugs and GER incidence in anesthetized dogs, although opioids were not individually analyzed (García et al., 2013). Therefore, it is difficult to establish whether this drug predisposes to GER during anesthesia.
In dogs, pre-anesthetic meperidine has been associated with a reduction in the absolute risk of developing GER. Galatos and Raptopoulos (1995ab) anesthetized dogs with pentobarbital-halothane or with a combination of pentobarbital-halothanemeperidine. The group that received meperidine had lower GER incidence (10%) in comparison to the group that did not receive meperidine (16.3% to 17.4%). Wilson et al. (2008) demonstrated that administration of pre-anesthetic meperidine was associated with a 29% reduction in the absolute risk of GER in comparison to morphine.
Contractility of the LES is one of the factors that prevent regurgitation during anesthesia. Various hormones and neurotransmitters regulate this contractibility. It is known that non-adrenergic and noncholinergic (NANC) nerves regulate gastrointestinal peristalsis and relaxation mechanisms of the LES. NANC inhibitory nerves are responsible for most nerve induced relaxations of the gastrointestinal sphincteric muscle. Ketamine and midazolam produce a relaxation of LES muscles in rabbits by acting upon different NANC neurotransmitters (Kohjitani et al., 2005). N-methyl D-aspartate (NMDA) antagonists like ketamine can act differently depending on the region of the gastrointestinal tract where they are exerting its function or where they are located, and the species. It has been well established that ketamine reduces LES pressure by inhibiting non-adrenergic non-cholinergic receptors (Kohjitani et al., 2005).
Several induction agents are used in small animal anesthesia; two of the most common inducers are propofol and thiopental. Raptopoulos and Galatos (1997) showed that dogs induced with propofol had higher GER incidence during anesthesia than those induced with thiopental. It is believed that this is because propofol diminishes LES pressure. Although further research is needed to elucidate all the potential effects of anesthesia inductors on GER, thiopental should be used as an induction agent in patients with high risk of GER in anesthesia, considering aspects such as breed, body weight (> 40 kg), patient position and orthopedic surgery.
Other researchers reported 55% GER incidence using a morphine-thiopental-isoflurane protocol (Wilson et al., 2005; Wilson et al., 2006a). Wilson et al. (2007) compared the number of dogs that presented GER when using only meperidine, morphine, or meperidineacepromazine. They found that the dogs that received meperidine alone had a 55% decrease in the risk of developing GER and the group with meperdineacepromazine had a 27% decrease. Similar results were obtained in recent studies, where meperidine proved to be the drug less likely to induce GER in these patients (Rodríguez, 2010). Meperidine may reduce the possibility of GER in dogs. However, according to Wilson et al. (2005), it does not produce high quality sedation. Therefore, it is not useful to include it in the anesthetic protocol when GER prevention during anesthesia is desired (Wilson et al., 2005).
It must also be taken into consideration that halothane, nitric oxide, and sodium pentothal inhibit the transient relaxation of the esophageal sphincter (Cox et al., 1988). 14.44% of dogs anesthetized with halothane, isoflurane, and sevoflurane, and using acepromazine and morphine as pre-anesthetics, presented GER during anesthesia. This was attributed to acepromazine, since it decreases muscle tone of the LES and does not avoid morphine-induced vomit. Maintaining anesthesia with halothane, isoflurane, and sevoflurane did not have an influence on GER development during surgery (Wilson et al., 2005; Wilson et al., 2006; Lamata et al., 2012; García et al., 2013).
Influence of patient position on GER during anesthesia
There have been several studies in both human and veterinary surgery about the effect of patient position during surgery and the development of GER. For example, when dogs are positioned in ventral recumbency they present a reduction of barrier pressure in the LES during anesthesia (Pratschke et al., 2001). However, Galatos and Raptopoulos (1995b) mentioned that only the heavier patients placed in this position presented high incidence of reflux during anesthesia, and that patient weight showed no influence on reflux development when using other surgical positions. Furthermore, according to Favarato et al. (2011), decubitus position is not a predisposing factor of GER in anesthetized dogs.
A reduction of pressure of the LES in patients in ventral recumbency has been demonstrated by Pratschke et al. (2001) by placing deep-chested dogs on a flat, hard surface, and observing that thorax anatomy becomes distorted, particularly the diaphragm. This occurs as a result of the pressure placed on the sternum when the weight of the animal is in a vertical position, since body weight is normally supported by all four limbs (Pratschke et al., 2001). Similarly, this diaphragmatic distortion occurs in heavy dogs (Lamata et al., 2012). Since the diaphragm is vital in maintaining the pressure of the LES, the distortion created by the weight of the dog on the surgical table is an important part of the reduced protection by tone loss (Pratschke et al., 2001). However, Rodríguez (2010) reported that most patients that developed GER during anesthesia had been placed in right lateral recumbency. This is most likely because the right crus is larger and longer than the left; then, if the dog is placed in right lateral recumbency on top of a hard and flat surface, its weight will prevent the right crus from working adequately, favoring the appearance of reflux.
Preventing GER during anesthesia
The consequences of GER are not only dangerous, but also difficult to treat. It is better to prevent GER from occurring during anesthesia, and in the event that it does develop, the damage must be minimized (Ng and Smith, 2001). In humans, the methods utilized to decrease GER incidence and severity of the injuries consists of managing the amount of gastric content via fasting, decreasing its pH, and taking measures to maintain an adequate tone of the LES (Ng and Smith, 2001). In a review about physiological aspects of GER and aspiration in anesthetized patients, it was determined that total fasting (nil per os/NPO) is not the most suitable recommendation to decrease GER incidence. This is because patients with 24 hours of fasting produce more HCl with a more acidic pH. Adult patients can drink clear liquids up to three hours before anesthesia since this does not increase the risk of reflux. A minimum of five hours is required to evacuate a light meal, but more than nine hours are needed for a heavy meal (Ng and Smith, 2001).
In children, the minimum fasting time required of clear liquids (water, fruit juice without pulp, carbonated drinks, tea, and dextrose) to have an adequate gastric emptying without any digestive problems was two to six hours (López-Muñoz et al., 2002; Maharaj, 2009).
Prolonged fasting, generally starting the night before surgery, was traditionally recommended in veterinary medicine, though this practice has changed. Now it is recommended that adult dogs solid-food fast for five to ten hours and they may have access to water up to two to three hours before anesthesia (Raptopoulos and Galatos, 1997; Raptopoulos and Savas, 2004; Muir et al., 2007; Savas and Raptopoulos, 2009; Epstein and Swirsky, 2009). It has been proven that a fasting period of more than 18 hours decreases LES tone in anesthetized dogs, therefore favoring GER development (Galatos and Raptopoulos, 1995a).
Although oral antacids in gel form have proven effective for increasing the pH of gastric content, it is not advisable to use them before anesthesia since they can have fatal consequences if aspiration occurs. In humans, water-soluble antacids, such as sodium bicarbonate, can also lower the stomach pH without presenting this danger (Sánchez, 2002); however, safety and potential damage to respiratory system—in case of bronchoaspiration— have not been established in dogs.
Studies evaluating GER in anesthetized humans and dogs have focused on the use of prokinetics and medications to reduce gastric acidity to prevent reflux (Wilson et al., 2006b; Panti et al., 2009; Favarato et al., 2012). In humans, it is also known that drugs that decrease hydrochloric acid production in the stomach, such as ranitidine and omeprazole increase pH and gastric fluids during surgery and therefore decrease the risk of developing Mendelson’s syndrome (Grümberg, 2003; Moro, 2004). However, Tamhankar et al. (2004) reported that oral administration of omeprazole every 12 h for 7 days did not decrease GER. Esomeprazole is the proton pump inhibitor studied in dogs; dogs that received IV esomeprazole (1 mg/kg) alone in a prospective randomized placebo-controlled study presented significant increase in gastric and esophageal pH, but the drug did not significantly decrease GER frequency; however, combination of esomeprazole (1 mg/kg) and cisapride (1 mg/kg) IV was associated with significant decrease of reflux in anaesthetized dogs (Zacuto et al., 2012). Ranitidine has been used in dogs to reduce GER during anesthesia, but results vary. According to some reports, ranitidine increased LES tone when administered before anesthesia; and it prevented tone loss of the LES when used before atropine (Raptopoulos and Galatos, 1997; Harter et al., 1998; Burrows, 2006). It is important to consider that ranitidine has no effect on LES tone when it is administered after atropine (Harter et al., 1998); however, according to recent findings ranitidine does not reduce GER when administered to dogs as an intravenous bolus at a dose of 2 mg/kg 6 h before anesthesia (Favarato et al., 2012).
In regard to prokinetics used in human anesthesiology to prevent GER during anesthesia, it has been proven that administration of 200 mg erythromycin before surgery increases the stomach pH. This is due to the stimulation of motilin receptors that reduce gastrin levels (Anderson, 2010). Wilson et al. (2006b) showed that a low dose of metoclopramide did not have a significant effect on GER incidence in dogs; however, a high dose (bolus loading dose of 1 mg/kg, IV, followed by continuous infusion at a rate of 1 mg/kg/h) reduced the relative risk to develop GER in 54%.
Occurrence of GER during anesthesia is a relatively frequent problem and a risk factor for further complications, such as aspiration pneumonia, esophagitis and esophageal strictures. The main factors involved include: Poodle patients, position (Trendelenburg or right lateral recumbence), orthopedic surgeries utilizing atropine and morphine as preanesthetics, and the use of propofol as an induction agent. A complete pre-surgery clinical history will also help to identify any existing digestive and/or esophageal disease, which may increase the risk of developing GER. Proper monitoring, along with the administration of certain drugs, such as prokinetics and proton pump inhibitors, can diminish GER occurrence. Further studies are needed to establish preventive protocols during anesthetic procedures. Studies in humans have rendered a guide for pathophysiologic and epidemiologic considerations, symptom evaluation, diagnostic workup, medical therapy and surgical therapy for GERD. Studies on other triggering factors, in addition to their management and prevention, are also needed.
Conflicts of interest
The authors declare they have no conflicts of interest with regard to the work presented in this report.
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PRE-REQUISITE: You MUST have completed MOST of the Freshman or Sophomore Year in order to take this class.
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The superstar posted photos of her wearing Rita's joggers, cropped tee and snapback cap combo on her website Beyonce.com - think retro floral print gear paired with peep-toe heels and sharp shades. And can we just talk about those abs too? Wow.
Rita was also quick to share the love, posting the same photo on Instagram with the caption:
"My big sis, The queen to you...🙌 rocking my first Adidas loves Rita Ora collection! 🐝#unstoppable out for you August 26th. #thankyou #myfamilia #iloveyou @beyonce"
When queen Bey is seen showcasing your latest fashion designs it's fair to say it's going to be a sell out, so we're guessing Rita was left feeling delighted.
The collection doesn't land in stores until 26th August but we already want it all. Especially the oversized floral crop top.
While rumours over Beyonce and Jay Z's marriage problems continue - the power couple are still going all out during their On the Run tour to prove otherwise.
The PDA's are a regular thing on-stage and the singer's Instagram account and website reveal that, actually, her and her man are unstoppable.
LOVE QUEEN BEY'S STYLE? Take a look through this gallery to see more looks from the star:
MORE! Watch all the latest on Bey right here.


Police in the conservative province of Aceh have arrested two university students accused of same-sex relations after a raid, LGBT activists confirmed on Friday.
Local residents in Banda Aceh, the capital of Aceh, the only province in Indonesia that adheres to the strict code of Islamic Sharia law, broke into the student accommodation on Thursday, confiscated condoms and telephones, and handed them over to the authorities, an activist, who requested anonymity, told EFE.
The arrested students are 21- and 24-years old; one is of Christian Batak ethnicity, while the other is Muslim.
The head of the investigation department of the Religious police, Marzuki, told the local portal Serambi that one of those arrested had admitted to the charges.
The crime of "Liwath", or sodomy among men, is punishable with up to 100 lashes.
Last year, two men were punished for engaging in same-sex relationships with 83 lashes in public.
At least 527 people have received similar punishments between 2016 and October 2017 for offenses such as gambling, alcohol consumption or adultery, according to the Institute for Reform of Criminal Justice.
NGOs and activists have denounced a recent spike in repression against the LGBT community in Indonesia, home to the world's largest Muslim population.


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LEGO The Hobbit announced for release next year
Warner Bros and TT Games have announced the latest in the LEGO licensing crossovers LEGO The Hobbit.
The new game will follow the same plot line as the first two films from The Hobbit trilogy with the LEGO franchise's usual sense of humour.
TT Games' Tom Stone said, “We are thrilled to depict the characters and environments of Peter Jackson’s Middle-earth in LEGO form with the LEGO The Hobbit video game. Our family-friendly take on these thrilling adventures will have kids and parents playing and laughing together as they build and explore in LEGO Middle-Earth.”
LEGO The Hobbit will be released on PS4, PS3, PS Vita, Xbox One, Xbox 360, Wii U, 3DS, PC and Mac in the spring of 2014.
- PlayStation Home to close next year
- New The Evil Within video offers up a survival lesson
- Shadow Of Mordor Season Pass trailer arrives teasing the game's DLC
- Excited about No Man's Sky? Now you can help make it
- Creative Assembly has something cool to reveal after Alien: Isolation is out the door
- Defiance gets renewed by SyFy for a third season
- Deadly Premonition creator's new game D4: Dark Dreams Don't Die not doing so well
- Ion Storm had begun planning Deus Ex 3 when they closed back in 2006
- Bungie closes Destiny's Loot Cave exploit

domain: news


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Why too much attachment is bad for Love life
Getting too connected to someone in a relationship is normal. Expressing and showing your love out in public is nothing new for two lovers. You always want your spouse to be there with you through all the good and the bad situations. You want them to be there with you at all times. However, many love experts have discussed adversely showing too much attachment is bad for a Love life.
We are born into the social context of our family and easily need to develop ways to getting our needs met by our caretakers. Based on our early psychological surroundings, we make the best variation to get our needs met by the possibility caretakers we have available to us, usually our parents or other family members.
Image source: lifehack.org
A person truly in love with another facilitates and cares about you for that unique one selflessly, without anticipating anything in come back. If any of the partners does not feel this, then it isn’t a true relationship. The type of exaggerated connection where even one of the partners has selfish intentions, like getting economical support or just as a source of pleasure, in that situation they put on an extreme show of love to improve individual benefits. Such connections are ruined from the beginning.

domain: sociology


Hardware Roundup: Monday Edition
Today's roundup includes a pair of gaming mice, one newly released and one that has been out a while. The newer of the two is the GX-Gaming Gila from Genius. The second device is the Cooler Master CM Storm Sentinel Advance II gaming mouse. We have another pair of reviews covering computer cases in the roundup with the first being the Corsair 500R Mid-Tower Case which is a member of the Carbide series from Corsair. The second is on the NZXT Phantom 820 full-tower chassis for those wanting more room for components.
Corsair Carbide Series 500R Case @ ThinkComputers
NZXT Phantom 820 Tower Computer Case @ Benchmark Reviews
Dead Space 3 PC Graphics Test @ TechSpot
GX-Gaming Gila @ LanOC Reviews
Cooler Master CM Storm Sentinel Advance II Gaming Mouse Revisited @ Madshrimps
Leading or Force Feeding? @ Computer Ed


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Image Source: Visual China
BEIJING, April 24 (TMTPOST) — TikTok’s parent company ByteDance has recently started testing its music streaming app Qishui Music.
Qishui Music is a music streaming platform designed for young users who enjoy trendy music, according to ByteDance. The music platform focuses on alternative music and recommends songs to users based on their preferences.
In addition, Qishui Music’s account is also linked to TikTok’s Chinese sister app Douyin. This means that follows, fans and music collections on a Douyin account can be shared with Qishui Music.
Different from counterparts such as QQ Music, NetEase Music and Kugou Music, Qishui Music has a simple user interface design, according to China Business Journal.
The new music streaming platform from ByteDance has a small music library due to the lack of licenses,日博网站多少, which is the platform’s biggest shortcoming so far. China Business Journal noticed that the platform has only uploaded some songs from popular artists like Jay Chou.
Social media feature is an important way for music streaming platforms to stimulate user interaction. Qishui Music’s founder Wang Lei wishes to build Qishui Music as the Bilibili in music. Bilibili is a popular video site in China that allows users to post bulletin comments real-time on videos. However, Qishui Music has not displayed its social features yet.
ByteDance has already penetrated the music market through Douyin before developing its dedicated music streaming app. Short video platforms, such as Douyin, have become an important channel for music to gain popularity in recent years.
Nearly 80% of music artists would promote their music through short video platforms. In 2021, almost all songs on Tencent Music Entertainment’s Top Ten Popular Songs of the Year were popular songs on Douyin.

domain: artistic


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Complete with a tennis court, pool and plenty of space for both a seaplane and a yacht, telecom magnate Bruce McCaw’s Hunts Point estate is listed for sale at $ 85 million — reportedly the highest price in the history of the local real estate listing service.
Though Hunts Point is lined with plenty of luxury waterfront homes, the 4.3-acre parcel is larger than others and includes a five-bedroom, 10-bath mansion, plus a beach house, staff house and cabana, according to the property listing.
Space for luxuries isn’t an issue: “Boats, seaplane, jet skis and a yacht of up to 150” [feet] are all accommodated ”at the property’s dock and 327 feet of Lake Washington shoreline.
“It’s a trophy property, really without peer,” said Windermere listing agent Anna Riley.
A large lawn offers space for hosting “fundraisers or holiday events,” and the dock is “like having a private marina,” Riley said. Modern zoning rules would not allow a dock of the same size or for the guest house to be as close to the water as it is, she said.
Los Angeles architect Richard Landry designed the sandstone home for saxophonist Kenny G, aka Kenneth Gorelick. The house was built in 1995. In 1999, Gorelick sold the home to Craig McCaw. At the time, neither side would reveal the purchase price, but the home had been listed for $ 26.5 million, The Seattle Times reported.
Craig later sold the home to his brother Bruce McCaw and Jolene McCaw, according to the Puget Sound Business Journal, which first reported the $ 85 million listing.
The McCaw family built its fortune after founding McCaw Cellular Communications, which was later sold to AT & T, and investing in other cellular companies as cell phones began to become a part of everyday life. Bruce McCaw also founded an insurance company and helped found Horizon Airlines.
The $ 85 million listing is the most expensive in the history of the Northwest Multiple Listing Service, which covers 26 Western Washington counties, the service confirmed.
The price is far beyond even the most extravagant homes to hit the local market in recent memory (though some luxury sales take place off market). In 2020, a property at the tip of Hunts Point became the most expensive local home sale at $ 60 million . Last year, the priciest sale in Western Washington was a mere $ 30.75 million, according to the NWMLS. Riley said the size and scale set the McCaw property apart.
Nationally, the number of luxury home sales spiked early in the pandemic but that has since begun to dip as the housing market slightly cools.
The priciest homes in the Seattle area often draw wealthy buyers from markets such as California, where prices are even higher.
Listing agents plan to market the Hunts Point home internationally. “The buying pool is not just our local pool of buyers,” Riley said. “Buyers who will look at this will have a broader perspective.”
This article includes information from the Seattle Times archives.

domain: finance


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Arcade Fire’s New Album ‘Everything Now’ Is A Boring Disappointment
The new Arcade Fire ‘Everything Now’ is out and I am afraid the reviews are not very positive, 69/100 on Metacritic? 5.6/10 for Pitchfork? Ouch! Even though a few blogs like NME are still kissing their ass, it’s not a very good score for the Montreal band, which brought so much hope for music back in 2004.
I don’t care much about the message of the album, I don’t even have any desire to go too deep in the lyrics, because I can’t find a song I really like on this album, only bits here and there, but this is not enough and this makes me depressed in a bad way. That ‘Chemistry’ song may be the worst of all, it sounds like a fake cheesy reggae-ska and, do yourself a favor, never listen to it after a song from ‘Funerals’, because you may start crying. This is what Arcade Fire is up to now? I can’t find a good thing to say about the very forgettable ‘Peter Pan’ which occurs just before…
There are plenty of dancefloors, retro dancefloors, ABBA was even mentioned when they released their single a few months ago, but honestly who needed this high-pitch ‘Electric Blue’ disco sang by Regine, or the reworked depressive funk of ‘Good God Damn’, or the uninspired sad dance of ‘Put Your Money On Me’? This song has its brief moments just like the next one ‘We don’t Deserve Love’, but emotion is basically too rare when I listen to the album, and Arcade Fire has always worked because of the emotional load some songs could convey.
There are three tracks called ‘Everything Now’, and two ‘Infinite Content’, may be an allusion to yes, the infinite content going in circle on the internet, as I understand that the themes of the album are infinite consumerism, overwhelming abundance of media and the anxiety that comes with technology, as the band went even through the pain to create a fake news website to promote the album.
‘Signs of Life’ is pure disco ball, but not that inventive, ‘Creature Comfort’ is a painful synth effort, and if they are looking for signs of life, this is exactly what I have been doing while listening to this album, it’s dead despite the omnipresent dance beats, and the social commentary is not going to wake me up, have you seen what’s happening in the lyrics of ‘Creature Comfort’? They suggest that kids who hate themselves want to die while listening to their first record! This could be seen as plain self-serving indulgence, self-martyrdom or painful narcissism. Who do they think they are? Lana Del Rey?
This is not a review, I have only listened to the album a few times, although I am certain my opinion will not change very much, but this is rather a complaint that one beloved band has become such a dull one, the disappointment is deep, the hope is gone, this can’t be a review, there are many more elaborated ones everywhere describing Arcade Fire’s absurd internet campaign that preceded the release of ‘Everything Now’, and detailing the tracks one by one, before diving into its circles of mediocrity.
And we all thought that a world falling apart was good for great art! If the Trump era is not even capable to bring us a good Arcade Fire album, what’s it good for? Truly nothing and nothing matters anymore, we live terrible times when a band who provided my bombastic emotional soundtrack in the early 00s is now recording an album as unexciting as ‘Everything Now’.


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$1,900 3 bed 1406 W Main Street, #114, Mesa AZ, 85201
Most errands require a car.
Many nearby public transportation options.
Biking is convenient for most trips.
Explore how far you can travel by car, bus, bike and foot from 1406 W Main Street, #114.
1406 W Main Street, #114 has good transit which means many nearby public transportation options.
RAIL Valley Metro Rail
40 Main St
104 Alma School Rd
30 University Dr
1406 W Main Street, #114 is in the city of Mesa, AZ. Mesa has an average Walk Score of 37 and has 439,041 residents.

domain: geography


Re: Lars Ulrich
Lars to me, does the job for metallica. he definetly can not be considered one of the best drummers around these day's, but aslong as he can drum for metallica im happy. listning to many of there bootlegs, you'l hear that he's getting quite lazy, such as not playing the proper begining to there song motorbreath, and sometimes not playing the double bass for dyers eve. i'd say he hit top notch during there ...and justice for all album, he definetly proved himself to be more then just your everyday thrash drummer. i give him credit for starting my favorite band, and also for keeping the energy in metallica. his drumming may be somewhat simple when comparing to other drummers, but his facial expressions will always be the best lol. I hope he can kick it back up on the their next album, to prove himself worthy of being a really good drummer. im a great fan through all of there albums, including the load era, st-anger, and S&M, and i hope it continues to be like that for there next album.


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Pass of the Five Elements
The Pass of the Five Elements, in Iron Mountain, leads to many destinations. It is one way to enter the World Above, and it is said to be the only point of entrance to the Twelve Kingdoms which does not conflict with the protective boundaries created by the Dragon.
It has a "guardian who returns" associated with it. (from Connections Readings)


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Cute and small tattoos for girls could be hidden easily and could be positioned anyplace within the body. It’s true that girls love cute tattoos that have footage and meanings associated to their lives. Small tattoos categorical courage and also look engaging.
Opportunities are sooner or later in your life considering a small tattoo. These small tattoos will never trigger regret and can stand up to a time check. Small tattoos are usually well-liked with girls who are not yet ready to commit to large work. In all probability girls want to have simple designs that look good in the coming many years. Additionally they need one thing that’s significant and can remind them of important occasions, individuals, and concepts of their lives. Every time they take a look at a tattoo, they are reminded of its importance.
When you're nonetheless starting a tattoo, one of the simplest ways is to get one thing small. All the time keep in mind that removing a tattoo just isn’t straightforward. Fortuitously, we’ve got countless decisions for the woman's tattoos, whether or not the tattoo is on the wrist, neck, back, leg, or other body half that the woman needs for her paintings. Wanting for enjoyable design or something significant, you’ll be able to take a look at these cute and small tattoo concepts for girls for inspiration
- 1 Cute and small tattoos for girls with which means
- 1.1 1. 3D Butterfly Tattoo
- 1.2 2. 3D cute little tattoo
- 1.3 three. 3D Small Tattoos for Girls
- 1.4 four. 3D Tattoo For Girls
- 1.5 5. Superb Tattoos For Girls
- 1.6 6. Arrow Foot Tattoo
- 1.7 7.
- 1.8 8. Arrow Tattoo For Girls
- 1.9 9. Star Tattoo
- 1.10 10. Greatest Feminine Tattoos
- 1.11 11. Ear Tattoo
- 1.12 12. Tiger's Roar
- 1.13 13. Greatest Tiny Tattoos
- 1.14 14. Birds Tattoo
- 1.15 15. Butterfly Tattoo Design
- 1.16 16. Cherry Blossom Tattoo
- 1.17 17. Breast Tattoo Design
- 1.18 18. Claw Tattoo
- 1.19 19. Cool Tattoos for Girls Which means
- 1.20 20. Cross Tattoo Designs
- 1.21 21. Cute and small tattoos for girls
- 1.22 22. Cute Arrow Tattoo
- 1.23 23. Cute Girls Tattoos
- 1.24 24. Cute humming Fowl Tattoo
- 1.25 25. Cute Small Tattoo Designs
- 1.26 26. Cute Small Tattoos for Ladies
- 1.27 27. Cute Small Tattoos
- 1.28 28. Heartbeat
- 1.29 29. Cute Cross
- 1.30 30. Jewish Star
- 1.31 31. Cute little tattoos with which means
- 1.32 32. Cute Star Tattoo For Girls
- 1.33 33. Cute Tattoo
- 1.34 34. Cute Tattoo Ideas
- 1.35 35. Cute Tattoos for Girls
- 1.36 36. Moon Tattoo
- 1.37 37. Dove Tattoo
- 1.38 38. Elephant with Umbrella
- 1.39 39. Feather Tattoo For Girls
- 1.40 40. Tribal Tattoo
- 1.41 41. Blossoming Tons
- 1.42 42. Flower Tattoos
- 1.43 43. Foot tattoo for girls
- 1.44 44. Fruit Tattoo
- 1.45 45. Ghost Tattoo Design
- 1.46 46. Girls Small Tattoos
- 1.47 47. Hearts Tattoo
- 1.48 48. Little Coronary heart
- 1.49 49. Tribal Tattoo Designs
- 1.50 50. Lion Tattoos for Girls
- 1.51 51. Mandala Tattoo For Girls
- 1.52 52. Tattoos for Girls
- 1.53 53. Number Tattoos
- 1.54 54. Owl Tattoo
- 1.55 55. Owl Tattoo
- 1.56 56. Pineapple-Tattoo Designs
- 1.57 57. QR Code Tattoo
- 1.58 58. The Queen of the Coronary heart
- 1.59 59. Quotes Tattoos for girls
- 1.60 60. Yin Yang Tattoos for Girls
- 1.61 61. White Tattoo Ink
- 1.62 62. Rabbit Tattoo
- 1.63 63. Rabbit Tattoos for Girls
- 1.64 64. Foot Tattoo
- 1.65 65. Rose Tattoo
- 1.66 66. Butterfly Tattoo
- 1.67 67. Guitar Tattoo
- 1.68 68. Skull and Cross
- 1.69 69. Small chook tattoos
- 1.70 70. Small Butterfly Tattoo
- 1.71 71.
- 1.72 72. Small Cute Butterfly Feed
- 1.73 73. Small Elephant
- 1.74 74. Small Flower Tattoo
- 1.75 75. Clam Shell Small Tattoo
- 1.76 76. Xoxo
- 1.77 77. A small heart tattoo on the wrist
- 1.78 78. Small Infinity tattoo with finger
- 1.79 79. Fowl Tattoos for Girls
- 1.80 80. Little Feather
- 1.81 81. Small Rose Tattoos for Girls
- 1.82 82. Smile Tattoo
- 1.83 83. Tribal Tattoo Designs
- 1.84 84. Small Tattoo Designs for Ladies
- 1.85 85. Small Tattoos for Girls
- 1.86 86. Symbolic Tattoo
- 1.87 87. Small tattoos for girls with which means
- 1.88 88. Small Rose Tattoos for Girls
- 1.89 89. Small Ship Tattoo
- 1.90 90. Small and easy
- 1.91 91. Peter Pan
- 1.92 92. Symbolic citation Tattoos
- 1.93 93. Symbolic tattoo for girls
- 1.94 94. The Constellations
- 1.95 95. Diamond Tattoo
- 1.96 96. Cute Tiger Head
- 1.97 97. World Map Tattoo
- 1.98 98. Wanderlust Tattoo
- 1.99 99. Sparrow
- 1.100 100. Crescent
- 1.101 101. Wrist Tattoo
- 1.102 102. Simply Reside
- 1.103 103. No Worry
- 1.104 104. Celtic Triskelion
- 1.105 105. Small Balloon Tattoo
- 1.106 106. The Cheshire Cat
- 1.107 107. Three Coronary heart Tattoos
- 1.108 108. Tree Tattoo
- 1.109 109. Tribal Lotus
- 1.110 110. Tribal Lotus Tattoo
- 2 The most typical small tattoos for
Cute and small tattoos for girls with which means
1. 3D Butterfly Tattoo
Originally Posted by 3d-hd-tattoos
Butterfly tattoo is the most effective presentation of progress and rebirth.
2. 3D cute little tattoo
Dream is a wish your heart does.
three. 3D Small Tattoos for Girls
Initially Posted by 3d-womentattoo
Bow tattoos are very female.
four. 3D Tattoo For Girls
Originally Posted by galknows
Butterfly represents grace and change. Because they are not such a phenomenal caterpillar, they develop into a gorgeous butterfly.
5. Superb Tattoos For Girls
Originally Posted by popsugar
This can be a fantastic lotus tattoo.
6. Arrow Foot Tattoo
The arrow symbolizes focus to realize the objective with confidence.
The feathers hanging on the arrow create an admirable effect.
8. Arrow Tattoo For Girls
arrow high-quality and delicate strains work greatest for tattooing.
9. Star Tattoo
This can be a trendy design created on the chest.
10. Greatest Feminine Tattoos
More and extra individuals have liked and practiced tattoos.
11. Ear Tattoo
Tattoos for girls have develop into a style image.
12. Tiger's Roar
Small tattoos provide the attraction that fits the feminine magnificence.
13. Greatest Tiny Tattoos
Heart tattoos are often a logo of affection.
14. Birds Tattoo
Small tattoos often include totally different symbols and patterns that are very related
15. Butterfly Tattoo Design
Butterfly tattoo is sort of widespread for celebrities similar to Brandy, Mariah Carey and Drew Barrymore.
16. Cherry Blossom Tattoo
Originally posted by slodive
Very trendy cherry blossom tattoo.
17. Breast Tattoo Design
Originally Posted by inkme.tattoo
Getting a tattoo underneath or under the breast is turning into in style in the present day. Rihanna has a tattoo on her chest and makes her attractive.
18. Claw Tattoo
A stunning twist of abnormal paws
19. Cool Tattoos for Girls Which means
This can be a private tattoo.
20. Cross Tattoo Designs
Cross tattooing might be associated with other symbols.
21. Cute and small tattoos for girls
The suitable notice for music lovers.
22. Cute Arrow Tattoo
Girls nowadays tattoos are socially acceptable, because most celebrities wear them.
23. Cute Girls Tattoos
For Animal Lovers.
24. Cute humming Fowl Tattoo
Originally written by Garant-ps
Feminine tattoos are not surprising and ladies are not criticized by physique ink.
25. Cute Small Tattoo Designs
Girls' tattoo designs are much less aggressive than men's tattoo designs.
26. Cute Small Tattoos for Ladies
You Only Reside Once.
27. Cute Small Tattoos
Initially Posted by Pinterest
Small tattoos are often chosen for tattoo lovers as a result of they are very reasonably priced.
29. Cute Cross
Small tattoos are very straightforward to hide in the event you need your work.
30. Jewish Star
One of the in style areas for smaller tattoos is finger and wrist.
31. Cute little tattoos with which means
32. Cute Star Tattoo For Girls
Originally Posted by shadibeautytips
Star tattoos have been there earlier than and are thought-about one of the oldest tattoo designs.
33. Cute Tattoo
This cute elephant plays with water.
34. Cute Tattoo Ideas
Initially Posted by theceleb
A small tattoo can look trendy in girls.
35. Cute Tattoos for Girls
Initially written by tattoo designs
A tremendous floral finger tattoo.
36. Moon Tattoo
This crescent tattoo is made in tribal design.
37. Dove Tattoo
Doves are often utilized in weddings as they symbolize peace, love and the start of a brand new life collectively.
38. Elephant with Umbrella
A small tattoo doesn’t harm anybody.
39. Feather Tattoo For Girls
If you wish to maintain it simple, you get a small however meaningful tattoo.
40. Tribal Tattoo
There are many small tattoos for girls, you’ll want to choose the suitable image.
41. Blossoming Tons
In the event you look intently on the design, you will see that that it’s shaded by dots. This type could be time consuming, however the result is awesome.
42. Flower Tattoos
Rose Tattoos are admired by each ladies and males.
43. Foot tattoo for girls
Swivel stars in your ft can create a horny style assertion.
44. Fruit Tattoo
Most frequently individuals marvel what is the story behind the tattoo.
45. Ghost Tattoo Design
The ghost tattoo is enjoyable but not too scary.
46. Girls Small Tattoos
This reminder that you must continue climbing in these mountains.
47. Hearts Tattoo
It’s clear that heart tattoos are a typical symbol of affection.
48. Little Coronary heart
Originally Posted by buzzfeed
Hearts carries love and ardour
49. Tribal Tattoo Designs
Tribal solar tattoo is a logo of endurance, power and transformation
50. Lion Tattoos for Girls
The lion symbolizes braveness, loyalty, and robust will.
51. Mandala Tattoo For Girls
Floral tattoos characterize nature.
52. Tattoos for Girls
This is small and easy but very important to the consumer.
53. Number Tattoos
A big variety of users.
54. Owl Tattoo
Originally Posted by hd-tattoos
Owl tattoo is a logo of wisdom.
55. Owl Tattoo
The unique People have the assumption that the owl is the protector of sacred information.
56. Pineapple-Tattoo Designs
Fruit Tattoos are filled with meanings.
57. QR Code Tattoo
You can also make this personal by together with your e mail handle, telephone number, or different text.
58. The Queen of the Coronary heart
Heart tattoos have been a well-liked design additionally in the early days
59. Quotes Tattoos for girls
Do you’re keen on me for who I’m
60. Yin Yang Tattoos for Girls
Small tattoos are often placed on the neck, wrist, arm or leg.
61. White Tattoo Ink
This tattoo means it's not over yet and you’ll be able to anticipate more to return.
62. Rabbit Tattoo
Rabbit tattoo is a logo of comfort and abundance.
63. Rabbit Tattoos for Girls
This can be a good black tattoo for rabbit lovers.
64. Foot Tattoo
Symbol of Stability
65. Rose Tattoo
In historic Persian culture, roses are a logo of love and ardour
66. Butterfly Tattoo
Butterfly could be very fashionable amongst girls as a result of they are lovely and symbolize transformation.
67. Guitar Tattoo
Simple tattoos can look good.
68. Skull and Cross
Sculls can mean numerous things, however it may also be used as an inventive expression
69. Small chook tattoos
Small tattoos are much less noticeable.
70. Small Butterfly Tattoo
Butterfly tattoos are lovely and delicate.
Coconut symbolizes safety because its fruit is troublesome to obtain as a result of its big peak.
72. Small Cute Butterfly Feed
This is an ideal tattoo design for girls.
73. Small Elephant
Ft are probably the most common tattoo placements for girls.
74. Small Flower Tattoo
Along with choosing engaging tattoo design, you additionally have to feel its which means.
75. Clam Shell Small Tattoo
Adding tattoos to your ft makes it more lovely.
Trendy and trendy tattoo for everybody.
77. A small heart tattoo on the wrist
The human coronary heart is what retains us alive.
78. Small Infinity tattoo with finger
Infinity symbolizes infinite prospects in life.
79. Fowl Tattoos for Girls
Chook Tattoos are of different shapes and sizes.
80. Little Feather
Feather tattoos don't look just positive, they are also rich in history.
81. Small Rose Tattoos for Girls
Originally posted by poptattoos
Rose tattoos could be easy or complicated, but we can’t deny that it’s undoubtedly beauty.
82. Smile Tattoo
Typically phrase tattoos could be mixed with design parts.
83. Tribal Tattoo Designs
Tribal tattoos could be either bold or delicate.
84. Small Tattoo Designs for Ladies
Once you spend money on your love, you spend money on your life.
85. Small Tattoos for Girls
This can be a good selection for photographers.
86. Symbolic Tattoo
For All Harry Potter fanatics
87. Small tattoos for girls with which means
Coronary heart price tattoo is among the most artistic and coolest tattoo concepts.
88. Small Rose Tattoos for Girls
Along with love, roses also mean ardour and power.
89. Small Ship Tattoo
No matter its measurement, it still seems to be superb with its wonderful details
90. Small and easy
Lotus flowers are a logo of purity and rebirth.
91. Peter Pan
Good for your youngster!
92. Symbolic citation Tattoos
Refuse to embed
93. Symbolic tattoo for girls
This tattoo represents his grasp's diploma in linguistics.
94. The Constellations
The right tattoo concept for all astronomy lovers.
95. Diamond Tattoo
Diamonds symbolize beauty and prosperity.
96. Cute Tiger Head
The artist has achieved a superb job in tattooing.
97. World Map Tattoo
This can be a good tattoo for vacationers.
98. Wanderlust Tattoo
The tattoo of the Wanderlust word is right for vacationers.
Whether black or colored, the tattoo of a sparrow continues to be a tremendous concept of a small tattoo.
Ankles are one of the best area for small tattoo ideas.
101. Wrist Tattoo
Wrist is a standard place for a small and modern tattoo.
102. Simply Reside
Collar bone is one of the best tattoo.
103. No Worry
This phrase tattoo appears really good on the ft.
104. Celtic Triskelion
Tattoos on the foot could be conveniently hidden.
105. Small Balloon Tattoo
This seems very cute
106. The Cheshire Cat
I might attraction that this tattoo driver loves Alice in Wonderland.
107. Three Coronary heart Tattoos
Three hearts in several sizes are simply extremely trendy.
108. Tree Tattoo
In most cultures, timber are thought-about sacred.
109. Tribal Lotus
Lotus tattoo just isn’t only lovely and fashionable, it is filled with several meanings.
110. Tribal Lotus Tattoo
Lotus is a logo of purity and divine magnificence
The most typical small tattoos for
can be used. Actually, the alternatives are infinite. One of the crucial widespread tattoos for girls is a flower tattoo. It may well range from totally different flower varieties and may be printed on the wrist, spine or stretch arm. A coronary heart tattoo is another widespread design that describes love. It may be printed in pink, pink or black. Regardless of the design you choose, be sure to are acquainted with its which means
Phrase tattoos are also widespread among girls, we’ve seen many instances where mothers and daughters get tattoos. It can be both a romantic word or an inspirational word that you simply do with the artistic font of your selection. Butterfly tattoos are also most popular by girls. Typically it’s also possible to add some flowers to it. Different fashions embrace a swallow and Dreamcatcher tattoo. Regardless of your tattoo design, ensure that it appears superb even if it is small.
All the time keep in mind that at the finish of the day, the proper tattoo selection for girls is totally your duty. There could also be meanings behind these tattoos, but it’s assumed that for you, it might mean a totally totally different one. The whole lot comes to your private determination. Most individuals assume that men have more tattoos than ladies. Nevertheless, in accordance with the newest survey, it is clear that there are more tattooed ladies than men. Tattoos are among the best ways to precise yourself. Show us a murals within the feedback under
Hey readers! I am a tattoo artist Jeffrey and day.) I’ve been drawing and portray my entire life, and at the end of high school, I decided that it was time for a higher problem, and I started to draw individuals. I'm so fortunate that I obtained to precise my creativity by means of physique artwork, and even more so that I might share my passion with my now spouse Emilien. She began working with me in my tattoo shop as a piercer and began writing and filming my creations on this weblog. I really like to hear from you and hope you take pleasure in our work collectively!


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When: May 13, 2015 at 6:30pm - 9:30pm
568 Seymour St
Vancouver, BC V6B 3h7
Google map and directions
Join us for the next of Mpowerment YVR's discussion nights that will look into representations of gay people and gay culture on television. We'll talk about topics such as diversity, stereotypes, and how our culture both shapes and in turn is shaped by portrayals of LGBT people in the media.
Beverages and snacks will be provided.
Access to the 2nd floor is via stairs or elevator.
Gender inclusive washrooms.
Mpowerment events are planned by and for young gay, bi and queer men, both cis and trans. We invite all guys who like guys and their friends to attend!


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Bürgen Gluten Free Apple Pies
12 slices Bürgen Gluten Free Splendid Sunflower & Chia Bread
3 tbsp water
3 tbsp brown sugar
1 tsp cornstarch
1 tsp cinnamon
a pinch of vanilla
1 whole star anise (optional)
a squeeze of lemon juice (optional)
To brush and sprinkle:
brown sugar (optional)
- Peel, core and chop the apples into small chunks.
- In a pot or saucepan, mix water, cornstarch, sugar, cinnamon, star anise and lemon juice. Bring to a boil, stirring constantly, until it thickens up.
- Add apples, toss to coat and set aside.
- Press a small bowl or large cookie cutter into each slice of bread to create a circle then flatten each slice with a rolling pin.
- Spread half the slices of Bürgen Gluten Free Splendid Sunflower & Chia Bread across the kitchen bench and place approx. 1 heaped tbsp of the apple filling in the centre of each.
- Place the remaining slices on top, then crimp edges with a fork to seal.
- Brush the top of each pie with melted butter.
- Sprinkle with brown sugar if desired.
- Bake for approx. 20 minutes at 180 degrees, until golden brown.
- Let cool for 10 minutes before serving,
- Enjoy as they are or drizzle in your favourite sauce (we recommend caramel). Tuck in!

domain: food


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As the title says, I’ll draw your character or design you one for a base of $5! I’m skilled in numerous art/illustration programs and a few animation software applications, and can draw most mammals, humans, supernatural creatures as well as fantasy creatures and snakes.
You may re-post and share these illustrations with credit but please don’t try to make new profit from my work. I will include the source file as well as plenty of other files if you would like to print this work or share with others online. I can work very fast, within the same day! All I ask is for communication with me so we can work on it quickly and efficiently, and for you to give me reference images or a detailed description. Each extra character included will be another $5, and I can include the entire process for another $5 if you’d like to learn how I work. Let me know if you have questions for me! Thank you!


Ready to change it up. Step out in these incredible purple based leggings and you will be the envy of your friends. Made from our signature buttery soft compressed material, these leggings are perfect for all types of exercise or sport.
- High waistband for extra support and comfort
- Rear zip pocket large enough for a phone
- 2 hip/thigh pockets
- Removable drawstring tie
- Flat stitched seams to prevent irritation
- Triangle gusset
- 27% spandex 73% polyester
As the material is compressed we suggest sizing up if you are between sizes. They are a snug fit as they are designed to give you the ultimate performance for sport.