text:
Miller Woods Race to Give a Little
The race is a mix of single track and wider grass pathways. There are no paved surfaces. The highest elevation on the property is 600 feet. The race has rolling hills and several larger hills. The race has partnered with The Give A Little Foundation to put on the event.
Parents, bring out the kids as there is an outdoor adventure program for kids ages 5-12 during the race.

domain: entertainment


text:
Friday, February 27, 2015
GAVRIL OF AQUINA ~ BY ~ AURRORA ST.JAMES
Gavril squatted before her, noting that she had removed the spit from the fire and eaten. She left the hare by the coals to warm and plenty remained, yet he couldn't muster an appetite. His breath rushed out in a white cloud as he skimmed a finger lightly down her cheek and tucked a strand of hair behind her ear. She shivered again beneath his touch. It was colder here on the mountain than their solitary blanket could warm.
He shouldn’t. He really shouldn’t.
When he was king, he might not have worried about her comfort. Parties, banquets, women, and liquor claimed him then. He'd been too wild to worry about comfort other than his own. But the man he'd become cared. Without another thought, he tugged off his boots, lifted the blanket, and slid in behind her. He shifted his big body against her and pulled her close.
He told himself he would stay just long enough to warm her up. Then he would move back to the other side of the fire and keep watch through the night.
He told himself she was better off being a little bit cold than being held by a man like him.
He told himself he was a fool.
No woman had ever felt so good in his arms.
Gavril slowly stroked her arm as he thought back over her story. She had suffered. But if she hadn't come to Aquina, they never would have met. And that he couldn't think about. If he were honest with himself, he wasn't ready to part from Shyla. Otherwise, he would have walked away, regardless of the danger to himself.
Shyla shifted, pressing her sweet bottom against his hips, as she settled into his embrace. Gavril thought he might die as his body immediately reacted. Blood shot to his groin, making him hard in seconds. It took all of his control not to roll her onto her back and kiss her right then, starting something he shouldn't — something he couldn’t — finish. Only his sheer will not to cause her more pain held him back.
With a ragged breath, he pulled the blanket about their shoulders, wrapped her in his embrace, and shared his warmth.
She sighed, her body relaxing against his as she absorbed his heat. Her hand settled over his, wrapped around her waist.
Gavril closed his eyes. In the two years since his return to Aquina, he hadn’t dared to dream of a future. He’d kept his thoughts firmly on surviving. On scratching out a living as best as a deposed king was able.
With Shyla, all that changed. Having her in his arms was like heaven itself. He felt like a man. Not a street urchin or a king. Just a simple man with a beautiful woman who stirred his body, mind, and if what she said was true, his magic. He felt lust rising sharp and hot, and, for the first time in years, a desire for... more.
He dreamed of lying before a hearth with her, snuggled as they were under a blanket, their bodies perspiring from an intense round of lovemaking. He dreamed of waking with her in his arms as the sun came through the shutters. He dreamed of growing old with Shyla in his embrace.
And he wanted that life like he'd never wanted anything before.
Gavril rubbed his thumb against her soft hand, savoring that small touch. He craved it like a dying man. In a sense, he was. He was dying of loneliness. Shyla’s simple kindness of taking him in eased that need inside him. Though he knew it was wrong, he soaked up every touch, every smile she offered.
As if she knew his need even in her sleep, Shyla wound her fingers with his and lightly squeezed.
He breathed deep, smelling the cinnamon scent of her hair, and allowed himself to relax. Heat from her body seeped into his skin.
With Shyla tight against him, wrapped in his arms, Gavril slept.

domain: artistic


text:
House prices in central London continued on a downward trend according to the latest survey by the Royal Institution of Chartered Surveyors (Rics).
The research showed the net proportion of property professionals reporting a fall had increased by 35% in May.
And London surveyors predict downward price pressure building over the coming quarter with 43% more contributors forecasting a drop.
Rics chief economist Simon Rubinsohn said: “Sadly, for the many young people looking to enter the property market, it is unlikely that we are seeing the emergence of a more affordable market.
“Instead, it appears to me that we are looking at a short term drop caused by the uncertainty resulting from the forthcoming EU Referendum coupled with a slowdown following the rush to get into the market ahead of the tax change on the purchase of investment properties.
“Certainly, that’s the story we are hearing from our members. There is not at this point a sense that a fundamental shift is taking place in the market.”
More than half of the professionals surveyed said that demand went down for a fourth consecutive month in May.
And agreed sales fell for a third month with a net balance of 59% of respondents reporting a fall rather than a rise in activity.
There was a reported rise in new landlord instructions in the lettings market while tenant demand remained stable over the last three months.

domain: finance


text:
Jason Murphy
Science Mid Term
Chapter 1:
1-1 The goal of science is to investigate and understand nature, to explain events in nature, and to use those explanations to make useful predictions
Science: an organized way of using evidence to learn about the natural world. Also refers to the body of knowledge that scientists have built up over years of using this process.
Evidence Based on Observation:
Observation: using 1 or more of the senses to gather information.
Data: evidence, the information gathered from observation.
Quantitative Observations: involve numbers, counting or measuring objects.
Qualitative Observations: involve characteristics that cannot be easily measured or counted, Ex: color or texture.
Inference: a logical interpretation based on prior knowledge and experience.
Hypothesis: a possible explanation for a set of observations or an answer to a scientific question.
A skeptical person continues to ask questions and looks for alternative explanations.
1-2 The factors in an experiment that can change are called variables.
Whenever possible, a hypothesis should be tested by an experiment in which only one variable is changed at a time. All other variables should be kept unchanged, or controlled.
Independent/manipulated variable: variable deliberately changed.
Dependent/responding variable: changes in response to the independent variable.
Theory: a hypothesis that is so well supported from evidence in numerous investigations.
In science, the word theory applies to a well tested explanation that unifies a broad range of observations.
1-3 Biology: study of life
Living things share several characteristics. These characteristics include the following:

Living things are made up of cells
Living things maintain a stable internal environment
Living things, taken as a group, change over time

Cell: small, self contained units that make up all life.
Sexual reproduction: two cells from different parents unite to produce the first cell of the new organism.
Asexual reproduction: the new organism has a single parent.
Metabolism: the combination of chemical reactions through which an organism builds up or breaks down materials as it carries out it’s life processes.
Homeostasis: the process by which organisms keep their internal conditions relatively stable.
Evolve: change over time.
The many levels at which life can be studied include molecules, cells, organisms, populations of a single organism, communities of populations living in the same area, and the biosphere.
1-4 Most scientists use the metric system when collecting data and performing experiments.
The metric system is a decimal system of measurement.
Microscopes are devices that produce magnified images of structures that are too small to see with the unaided eye.
Light microscopes produce magnified images by focusing visible light rays. Electron microscopes produce magnified images by focusing beams of electrons.
Compound light microscopes allow light to pass through the specimen and use two lenses to form an image.
Electron microscopes focus beams of electrons on specimens.
Cell culture: a group of cells, often isolated for experimentation.
Cell fractionation: process to separate cell parts.
Chapter 2:
2-1 The Nature of Matter
Atom: basic, smallest unit of matter
The subatomic particles that make up atoms are protons, neutrons, and electrons.
Nucleus: center of the cell, formed by protons and neutrons. Contains DNA, the blueprint for the cell.
Electron: negatively charged particles located on orbitals.
Proton: positively charged sub-atomic particle located in the nucleus of cells.
Element: a pure substance that can’t be broken down into a more simpler substance, consists entirely of one type of atom.
Isotopes: Atoms of the same element with a different atomic mass number.
Because they have the same number of electrons, all isotopes of an element have the same checmical properties.
Compound: A chemical compound is a substance formed by the combination of two or more elements in definite proportions.
The main types of bonds are ionic bonds and covalent bonds:
Ionic bonds: An ionic bond is formed when 1 or more electrons are transferred from one atom to another.
Ions: positively or negatively charged atoms
Covalent bonds: A covalent bond forms when electrons are shared between atoms.
Bonds are only dealing with the giving or sharing of electrons.
Molecule: The molecule is the smallest unit of most compounds. Ex: water molecule-2 hydrogen atoms, 1 oxygen atom.
When molecules are close together, a slight attraction can develop between the oppositely charged regions of nearby molecules. Chemists call such intermolecular forces of attraction, van der Waals forces.
2-2 A water molecule is polar because there is an uneven distribution of electrons between the oxygen and hydrogen atoms.
Cohesion: an attraction between molecules of the same substance. Ex: water
Adhesion: an attraction between molecules of different substances.
A mixture is a material composed of two or more elements or compounds that are physically mixed together but not chemically combined.
Solution: type of mixture
Solute: The substance that is dissolved.
Solvent: The substance in which the solute dissolves.
An acid is any compound that forms H+ ions in solution.
Acidic solutions contain higher concentrations of H+ ions than pure water and have pH values below 7.
A base is a compound that produces hydroxide ions in solution.
Basic, or alkaline, solutions contain lower concentrations of H+ ions than pure water and have pH values above 7.
Buffers are weak acids or bases that can react with strong acids or bases to prevent sharp, sudden changes in pH.
2-3
Monomers: smaller units of macromolecules.
Polymers: chains or joined monomers.
Four groups of organic compounds found in living things are carbohydrates, lipids, nucleic acids, and proteins.
Living things use carbohydrates as their main source of energy. Plants and some animals also use carbohydrates for structural purposes.
Monosaccharides: single sugar molecules, carbs.
Polysaccharides: large macromolecules formed from monosaccharides.
Lipids can be used to store energy. Some lipids are important parts of biological membranes and waterproof coverings.
Nucleic acids store and transmit hereditary, or genetic, information. Two kinds: RNA and DNA.
Nucleotides: Individual monomers
Proteins are polymers or molecules called amino acids (20 kinds)
Some proteins control the rate of reactions and regulate cell processes. Some are used to form bones and muscles. Others transport substances into or out of cells or help to fight disease.
2-4
A chemical reaction is a process that changes one set of chemicals into another set of chemicals.
Reactants are compounds entering the reaction, the compounds produced are called products.
Chemical reactions always involve the breaking of bonds in reactants and the formation of new bonds in products.
Chemical reactions that release energy often occur spontaneously. Chemical reactions that absorb energy will not occur without a source of energy.
Activation energy: energy needed to get a reaction started.
Catalyst: a substance that speeds up the rate of a chemical reaction.
Enzymes are proteins that act as biological catalysts.
Cells use enzymes to speed up chemical reactions that take place in cells.
Substrates: the reactants of enzyme-catalyzed reactions are known a substrates.
Chapter 7
7-1
Cells: the basic units of all forms of life.
Cell theory:

All living things are composed of cells.
Cells are the basic units of structure and function in living things.
New cells are produced from existing cells.

Cell Membrane: a thin, flexible barrier around the cell.
Cell Wall (plants only): strong layer around cell.
Cell walls and cell membranes protect and support cells, while allowing them to interact with their surroundings.
Nucleus: a large structure that contains all genetic material and controls cell activities.
Cytoplasm: material inside the cell membrane.
Biologists divide cells into two categories: eukaryotes and prokaryotes. The cells of eukaryotes have a nucleus, but the cells of prokaryotes do not.
Organelles: specialized structures that perform important cellular functions.
7-2
The main function of the cell wall is to provide support and protection for the cell.
Nucleolus: assembly of ribosomes
Nuclear envelope: double-membrane layer surrounding the nucleus.
Cytoskeleton: helps support the cell. The cytoskeleton is a network of protein filaments that helps the cell to maintain its shape. The cytoskeleton is also involved with many forms of cell movement.
Microtubules: hollow tubes of protein that maintain cell shape and serve as “tracks” along which organelles are moved.
Microfilaments: long, thin fibers that function in the movement and support of the cell.
Proteins are assembled on ribosomes, small particles of RNA and protein.
Ribosomes: produce proteins following coded instructions that come from the nucleus.
Endoplasmic Reticulum (ER): smooth-no ribosomes, rough-ribosomes. The ER is the organelle in which components of the cell membrane are assembled and some proteins are modified.
Golgi Apparatus: Enzymes in the Golgi Apparatus attach carbohydrates and lipids to proteins.
Lysosomes: Small organelles filled with enzymes that break down lipids, carbohydrates, and proteins from food into particles that can be used by the rest of the cell. Also break down old organelles to not clutter up the cell.
Vacuoles: Saclike structures used to store water, salts, proteins, and carbohydrates. Plant cells have a single large vacuole. Makes it possible for plants to support heavy structures.
Chloroplasts: Found in plants. Chloroplasts use the energy from sunlight to make energy-rich food molecules in a process known as photosynthesis.
Mitochandria: Organelles that release energy from stored food molecules. Mitochandria use energy from food to make high-energy compounds that the cell can use to power growth, development, and movement.
7-3
The cell membrane regulates what enters and leaves the cell and also provides protection and support.
Lipid bilayer: The core of nearly all cell membranes is a double-layered sheet called the lipid bilayer.
The concentration of a solution is the mass of solute in a given volume of solution, or mass/volume.
Diffusion: The process by which molecules move from an area where there is a higher concentration of molecules to an area of less concentration. When concentration is equal, it is at an equilibrium.
Diffusion causes many substances to move across a cell membrane but does not require the cell to use energy.
Selectively permeable: Most membranes are selectively permeable, meaning that some substances can pass through them and others cannot.
A process called osmosis allows water molecules to pass easily through most biological membranes. Osmosis is the diffusion of water through a selectively permeable membrane.
Isotonic: concentrations equal inside and outside of membrane
Hypotonic: more concentration on outside of membrane.
Hypertonic: more concentration inside of membrane.
Facilitated diffusion: helps diffusion of molecules across the membrane.
Active transport: The material moves from an area of lower concentration to an area of greater concentration in a process called active transport.
Endocytosis: taking material into the cell through infoldings, or pockets of the cell membrane.
Phagocytosis: engulfing of large particles located on the outside of the membrane.
Exocytosis: removal of large amounts of material.
7-4
Cells are the basic units of all organisms
A single-celled organism is also called a unicellular organism.
They grow, respond to the environment, and reproduce.
Colonial organisms live in groups of individuals of the same species that are attached to one another but have few specialized structures.
Organisms made up of many cells that work together are called multi-cellular organisms.
Multi-cellular organisms have cell specialization, or separate roles for each type of cell.
Cells in multicellular organisms are specialized to perform particular functions within the organisms.
Levels of organization:
The levels of organization in a multicellular organism are individual cells, tissues, organs, and organ systems.
Tissue: a tissue is a group of similar cells that perform a particular function.
Four main types:

Muscle, epithelial, nervous, and connective.

Epithelial tissues, such as skin cover or line body surfaces. Connective tissues include bone, blood, cartilage, and lymph.
Many groups of tissues work together as an organ.
A group of organs that work together to perform a specific function is called an organ system.
8-1
Energy and Life:
Plants and some other types of organisms are able to use light energy from the sun to produce food. Organisms such as plants, which can make their own food, are called autotrophs. Other organisms, such as animals, cannot use the sun’s energy directly. These organisms, known as heterotrophs, obtain energy from the foods they consume.
ATP=Adenosine triphosphate
ADP=Adenine diphosphate
The characteristics of ATP make it an exceptionally useful molecule that is used by all types of cells as their basic energy source.
8-2
Photosynthesis:
CO2 + H20 + energy (sunlight)=C6H12O6(glucose) + O2.
Jan van Helmont discovered water was a reactant through his plant and water experiment.
Priestly discovered oxygen as a product through his candle experiment with the glass jar.
Ingenhousz found sunlight as a reactant by performing Preistly’s experiment in the dark.
The experiments performed by van Helmont, Priestly, Ingenhousz, and other scientists reveal that in the presence of light, plants transform carbon dioxide and water into carbohydrates and release oxygen.
Photosynthesis uses the energy of sunlight to convert water and carbon dioxide into oxygen and high energy sugars.
In addition to water and carbon dioxide, photosynthesis requires light and chlorophyll, a molecule in chloroplasts.
Plants gather the sun’s energy with light-absorbing molecules called pigments. The plants’ principal pigment is chlorophyll.
Two types, chlorophyll a, and chlorophyll b.
8-3
Photosynthesis takes place inside chloroplasts. Saclike photosynthetic membranes called thylakoids. Thylakoids are arranged in stacks known as grana.
The Calvin cycle takes place in the stroma, the region outside the thylakoid membrane.
A carrier molecule is a compound that can accept pair of high-energy electrons and transfer them along with most of their energy to another molecule.
The light-dependent reactions produce oxygen gas to convert ADP and NADP+ into the energy carriers ATP and NADPH.
The Calvin cycle uses ATP and NADPH from the light dependent reactions to produce high energy sugars.
Factors Affecting Photosynthesis
-shortage of water can slow or stop photosynthesis
-temperature
-intensity of light also affects the rate at which photosynthesis occurs.
9-1
A calorie is the amount of energy needed to raise the temperature of 1 gram of water 1 degrees Celsius.
Glycolysis releases a small amount of energy.
Glycolysis, the Krebs cycle, and the electron transport chain make up a process called cellular respiration.
Cellular respiration is the process that releases energy by breaking down food molecules in the presence of oxygen.
Glycolysis is the process in which one molecule of glucose is broken in half, producing two molecules of pyruvic acid, a 3-carbon compound.
TermDefinitionautotrophorganisms such as plants, which make their own foodheterotrophorganisms such as animals, which obtain energy from foods they consumeATPone of the main chemical compounds that living things use to store energyphotosynthesiswhen plants use sunlight to convert water and carbon dioxide into oxygen and high-energy carbsohydrateschlorophyllthe plants principal pigmentthylakoidthe saclike photosynthetic membranes in chloroplastsstromathe region outside the thylakoid membranesNADP+a carrier moleculelight dependent reactionthe recation in plants which require lightATP synthasea protien contained in the membrane of the electron transport chaincalvin cyclewhen plants use the energy that ATP and NADPH contain to build high-energy compounds that can be stored for a long timecaloriethe amount of energy needed to raise the temperature of 1 gram of water 1 celcuis degreeglycolysisa process that releases only a small amount of energycellular respirationthe process that releases energy by breaking down food molecules in the presence of oxygenNAD+an electron carrier that accepts 4 electronsfermentationthe process of a non-present oxygen pathway and glycolysisanaerobicmeans to not require oxygenaerobicthe pathways in cellular respiration, which require oxygemkrebs cyclepyruvic acid produced in glycolysis, which passes to the second stage of cellular respirationelectron transport chainthe electrons passed from the carriers

domain: biology


text:
A randomized, double-blind, placebo-controlled trial of preemptive analgesia with bupivacaine in patients undergoing mastectomy for carcinoma of the breast.
Author(s): Zielinski J, Jaworski R, Smietanska I, Irga N, Wujtewicz M, Jaskiewicz J
Affiliation(s): Department of Surgical Oncology, Medical University of Gdansk, Gdansk, Poland.
Publication date & source: 2011-10, Med Sci Monit., 17(10):CR589-97.
BACKGROUND: In this prospective, randomized, placebo-controlled, double-blinded clinical trial we tested the hypothesis that preemptive analgesia with bupivacaine applied in the area of the surgical incision in patients undergoing mastectomy for breast cancer would reduce post-operative acute pain and would reduce the amount of analgesics used during surgery and in the post-operative period. MATERIAL/METHODS: Participants were assigned into 1 of 2 groups--with bupivacaine applied in the area of surgical incision or with placebo. We assessed the intraoperative consumption of fentanyl, the postoperative consumption of morphine delivered using a PCA method, and the subjective pain intensity according to VAS score reported by patients in the early post-operative period. RESULTS: Out of 121 consecutive cases qualified for mastectomy, 112 women were allocated randomly to 1 of 2 groups--group A (bupivacaine) and group B (placebo). The final study group comprised 106 breast cancer cases. Between the groups, a statistically significant difference was observed with respect to: lower fentanyl consumption during surgery (p = 0.011), lower morphine (delivered by means of a PCA) consumption between the 4-12th postoperative hours (p = 0.02) and significantly lower pain intensity assessed according to VAS score at the 4th and 12th hours after surgery (p = 0.004 and p = 0.02 respectively) for the group A patients. CONCLUSIONS: Preemptive analgesia application in the form of infiltration of the area of planned surgical incisions with bupivacaine in breast cancer patients undergoing mastectomy decreases post-operative pain sensation, limits the amount of fentanyl used during surgery, and reduces the demand for opiates in the hours soon after surgery.

domain: medical


text:
Sustanon 250 pris
Check with your pharmacist if you have questions about the best way to throw out drugs, sustanon 250 pris. Low levels of semen Testosterone plays an important role in semen production, sustanon 250 where to buy. Low levels will result in a decrease in the amount of semen being produced. He also experienced increased stamina during his workouts, sustanon 250 prix belgique. William says his results were incredible and has never seen gains this fast in the 5 years he s been weight training. What was your experience. Tell us about it in the comments below, sustanon 250 where to buy. D-Bal is best used when bulking and trying to build muscle, sustanon 250 prix tunisie. It can be combined with DecaDuro, Anadrole, Testo-Max or and Trenorol for further muscle gains. Some men will use as much as 80-100mg per day, but keep in mind this does increase the chance of side effects. Female Oxandrolone users will normally dose the steroid at 5-10mg per day, sustanon 250 pill.
Programme prise de volume musculaire
Furthermore, injectable Anadrol is more difficult to get hold of compared to orals, so there is no significant benefit to taking injectable Anadrol over oral Anadrol, other than slightly less liver strain, sustanon 250 pris. Profil d acides amines essentiels et non essentiels, sustanon 250 price south africa. Comme les proteines sont les elements constitutifs du muscle. HGH booster supplements reactivate your pituitary gland, so it operates like it did when you were young, sustanon 250 pill. Human growth hormone plays a central role in cell regeneration and metabolism. Regular exercise can also promote a healthy weight, sustanon 250 pill. Studies suggest those who are obese have lower testosterone levels. Androgens and anabolic steroids are used as replacement therapy to treat delayed puberty in adolescent boys, hypogonadism and impotence in men, and to treat breast cancer in women. They are also used to treat anemia, osteoporosis, weight loss and other conditions with hormonal imbalance, sustanon 250 reviews. The difference between a legal steroid and your average supplement is that legal steroids help naturally increase hormone levels, sustanon 250 pharmacie. When you train with weights, you stimulate certain androgen receptors.
Sustanon kullananların yorumları, sustanon 250 pills side effects
Sustanon 250 pris, commander stéroïdes en ligne gain de muscle..
Ils n ont pas besoin de savoir ce que vous ferez avec, sustanon 250 pris. Other ways to naturally optimize testosterone levels include, sustanon 250 pill. Avoiding tobacco Limiting stress Avoiding opioids or pain medications Maintaining a healthy body weight. This is why athletes who are bulking up prefer using Testosterone Propionate instead of Testosterone Enanthate, sustanon 250 price south africa. Fourthly, it is a huge help during cutting phases for athletes and bodybuilders who wish to burn excess fat while keeping lean muscles. Plus, despite protest from trans Australians saying that the move would make it unaffordable, Primoteston was removed from Australia s Pharmaceutical Benefits Scheme PBS in January 2018, meaning it would no longer be subsidized, sustanon 250 trt protocol. I have gone weeks without this medication because I was so broke that I couldn t afford it at its full cost price, and I know many people do the same thing. Mesterolone Sold under brand names such as Proviron, this anabolic steroid is principally for the treatment of low testosterone levels. Professional bodybuilders and athletes use it for physique-building and performance-enhancing purposes, although not commonly so, sustanon 250 trt protocol. The American Heritage Medical Dictionary Copyright 2007, 2004 by Houghton Mifflin Company. Published by Houghton Mifflin Company, sustanon 250 prix belgique..
Une entreprise reconnue dans le monde du bodybuilding, sustanon 250 pris. How Does It Work. Crazy Bulk Testo Max is powered by multiple ingredients, sustanon 250 prix. Deca Durabolin can produce androgenic side effects; however, the threshold tends to be rather high for most men, sustanon 250 reviews. Possible androgenic side effects of Deca Durabolin include acne, accelerated hair loss in those predisposed to male pattern baldness, and body hair growth. Rashes Hives Acne Blemishes Jaundice Redness Itching Swelling of hands, feet, ankles, mouth, face or lips Nausea Vomiting Diarrhea Constipation Indigestion Stomach cramping Loose stool Dark or bloody stool Dark or bloody urine Increase in hunger Increase in thirst excessive thirst Loss of appetite Chest pain Chest pressure Rapid heart beat Heart palpitations Trouble breathing Shortness of breath Depression Anxiety, tension, excessive stress Irritability Mood swings Agitation Uncontrollable anger Withdrawing Dysphoria Euphoria Paranoia Dizziness Confusion Foggy head Memory loss Forgetfulness Bad breath Fruity taste or smell to the breath Swollen gums Ulcerations or cancer sores in the mouth Toothache Breast enlargement Breast swelling or tenderness Male patterned balding Lower and deeper voice. Keeping track of how you are feeling when you are taking your Testosterone Propionate injections is important, sustanon 250 pill. Androgel may cause side effects such as difficulty urinating, swelling of the extremities or blood in urine. Androgel contains a synthetic version of the hormone testosterone, sustanon 250 price south africa. Les exercices qui sollicitent un maximum de muscles. De recentes etudes ont montre que plus un exercice sollicite de muscles, plus il stimule la liberation de testosterone, sustanon 250 prix tunisie.
Sustanon 250 pris, commander anabolisants stéroïdes en ligne carte visa..
Without a PCT plan, while you may very well recover it will take an enormous amount of time, sustanon 250 pris. How long does testosterone undecanoate stay in your system. In its injectable form, Nebido has an extremely long half life of up to three months, sustanon 250 where to buy. Pour les personnes agees Le remplacement de la testosterone ne devrait pas etre utilise chez les personnes agees en andropause diminution de la testosterone liee a l age, sustanon 250 pharmacie. On ne dispose pas de suffisamment d information sur l innocuite a long terme pour evaluer les risques de cancer de la prostate et de maladie cardiovasculaire chez les personnes agees ou d aggravation de l hypertrophie de la prostate pendant la prise de ce medicament. Pour maintenir vos niveaux de sucre a un taux normal, votre pancreas fait un effort supplementaires pour produire de l insuline, qui permet de transporter le sucre du sang dans les cellules pour etre metabolise en energie. En fin de compte, si les cellules sont exposees a l insuline pendant de longues periodes, vous developpez la resistance a l insuline, ce qui provoque le diabete de type 2, sustanon 250 wirkung. Drug Content Provided by IBM Micromedex. The dose of this medicine will be different for different patients, sustanon 250 uk. Improving sleep Losing weight Staying active, sustanon 250 prix belgique. These are also good for your overall health..
Prescription treatments can help to raise levels of testosterone to improve symptoms, sustanon 250 pris. Toutefois, en augmentant la concentration de testosterone dans le sang avec des injections de steroides anabolisants, il y a un blocage continu de la production de sperme , conduisant a une situation d azoospermie, sustanon 250 pharmacie. Le corps ne peut pas dire si l origine de l hormone testosterone est naturelle ou artificielle, de sorte que la formation des spermatozoides dans les testicules est interrompue et cela entraine une sterilite endocrinienne. Quant aux anabolisants naturels pour chevaux , ils se composent d extraits de plantes soigneusement selectionnees. En effet, les anabolisants naturels peuvent etre pris par les chevaux puisqu ils ne contiennent pas de steroides d origine animale, sustanon 250 where to buy. Testosterone is available in many forms, including injections, patches, and gels. The dosage form of testosterone most commonly prescribed is a gel, sustanon 250 where to buy. Using corticosteroid medications for a long time can make it more difficult for your body to respond to physical stress. Before having surgery or emergency treatment, or if you get a serious illness injury, tell your doctor or dentist that you are using this medication or have used this medication within the past 12 months, sustanon 250 pharmacie. Red blood cells also help to slow down the accumulation of lactic acid in your muscle tissues, sustanon 250 mg. With Var, you will have the strength to repeat compound lifts in the gym over a much longer length of time..
Take a quick 1-3 minute assessment, sustanon 250 pris. The medical condition, levels of testosterone in the blood, and response to the treatment determine the dosage, sustanon 250 prix. While taking the medication, you should not suddenly stop using it without consulting your doctor, who will gradually reduce the dosage. Un des anabolisants les plus prises sur le marche est l Anavar c est le nom de marque de la dihydrotestosterone, la derivee de l anabolisant appele Oxandrolone. L Anavar fonctionne comme les autres anabolisants et aide le developpement de masse musculaire tout en aidant le corps a devenir plus efficace, sustanon 250 price in india. Les grands essais recents pour mesurer les effets du traitement hormonal chez la femme ont dure pres de huit ans et ont porte sur des milliers de volontaires. L andropause n est pas physiologique chez l homme, sustanon 250 mg. As with all results from this slower acting steroid, it will take time for endurance benefits to be felt but once they are you ll quickly find your previous limits can be pushed through easily, simply meaning your workout intensity will be increased and you won t find yourself feeling fatigued at the point where you previously did, sustanon 250 uk. Muscle gains will greatly depend on dose, diet, and training as well as genetics and age. It is not known whether anabolic steroids are excreted in human milk, sustanon 250 reviews. Many drugs are excreted in human milk and because of the potential for adverse reactions in nursing infants from WINSTROL anabolic steroids , a decision should be made whether to discontinue nursing or discontinue the drug, taking into account the importance of the drug to the mother..
Sustanon 250 pris, stéroïdes légaux à vendre médicaments de musculation.
Sustanon 250mg/ml x 10ml
Primo Tabs 25 mg (50 tabs)
Oxydrolone 50 mg (50 tabs)
Generic HGH Black tops, 100iu
Oxa-Max 10 mg (100 tabs)
Anavar 10mg x 50 tablets
Winstrol – 50mg
Anadrol 50 Maha Pharma
Para Pharma UK Domestic
Pas cher acheter stéroïdes en ligne carte visa.
Sustanon 250 pris, programme prise de volume musculaire
CRN-5, a creatine supplement, and Pre-Train, a pre-workout supplement, are both gluten-free products sold by Crazy Bulk, sustanon 250 pris. Qui est touche par la gynecomastie. La gynecomastie n est pas contagieuse ; cependant les hommes de tout age peuvent etre atteints par la maladie, sustanon 250 pills side effects. C est un systeme de transduction qui contient le recepteur, un systeme proteique de couplage et des proteines effectrices, sustanon 250 pharmacie. Ces proteines vont modifier l activite biologique des cellules cibles par l intermediaire de phosphorylation d autres proteines deja presentes dans la membrane. In short, Trenbolone promotes protein synthesis as well as nitrogen retention. With its ability, Tren provides a result of mass and strength gain, sustanon 250 opis. As for women, this mild nature is in part what makes it a fantastic choice, sustanon 250 where to buy. The Methenolone hormone carries several traits similar to many other anabolic steroids. Worsening of Benign Prostatic Hyperplasia BPH and Potential Risk of Prostate Cancer. Patients with BPH treated with androgens are at an increased risk for worsening of signs and symptoms of BPH, sustanon 250 prix tunisie., www.yggabercynonpta.com/group/mysite-200-group/discussion/10578004-64b8-418c-8d2b-3fc845650e55.
Trenbolone is therefore illegal for any type of use as an anabolic steroid and is subject to sanctions by all world sports anti-doping organizations, sustanon 250 pris. Any gains that you make during a Primo cycle will be dry and vascular, sustanon 250 risques. Also, get ready for moderate strength gains. This medication can increase the risk of having a heart attack or stroke. Therefore, you should monitor your blood pressure daily regardless of when you began treatment, sustanon 250 reviews. Female Nolvadex doses should be less than a male, with cycles also being shorter. A protocol Dave Crosland reports as having some success is, sustanon 250 prix belgique. If the patient becomes pregnant while taking androgens, she should be apprised of the potential hazard to the fetus. This preparation is also contraindicated in patients with a history of hypersensitivity to any of its components, sustanon 250 prix tunisie. Elle a un impact direct sur la secretion de la prolactine, sustanon 250 where to buy. Car, en effet, la pathologie induit une elevation de la secretion de prolactine..
Pas cher acheter légal stéroïde expédition dans le monde entier.
Sustanon 250 pris, pas cher prix commander stéroïdes en ligne paypal.
It s also been enough to keep the demand for this steroid fairly high, as well as plague the market with counterfeits, sustanon 250 pris.. Potential for Adverse Effects on Spermatogenesis, sustanon 250 pris. With large doses of exogenous androgens, including Testosterone Gel 1 , spermatogenesis may be suppressed through feedback inhibition of pituitary follicle-stimulating hormone FSH which could possibly lead to adverse effects on semen parameters including sperm count. Prolonged use of high doses of orally active 17-alpha-alkyl androgens e. Peliosis hepatis can be a life-threatening or fatal complication. Long-term therapy with intramuscular testosterone enanthate has produced multiple hepatic adenomas.
Ce mardi la, Benou aura environ 1 chance sur 2 700 de frapper la Terre, programme prise de volume musculaire.. Anadrol and Dianabol are only examples of aromatizable steroids as there are many others, however, these steroids are having higher chances of causing Gynecomastia as they are highly aromatized by the body, programme prise de volume musculaire. Yet, thinking that other steroids won t cause gynecomastia would be a big mistake. How much estrogen levels you have in the body is directly related to the growth on breast tissues and while some steroids offer only a bit of estrogen, others offer a lot. The reason why elder men or boys during puberty have higher chances to get gyno is because there are estrogens female sex hormone and androgen male sex hormone and during such periods, there are higher chances of getting imbalances in those hormone levels for some it may increase, but for others it would decrease.

domain: health


text:
Alyssa: Tonia Says means so much to so many people, including myself.
Tonia Says was one of the first blogs I came across when I began writing about my own experience with CP. Before then, I had little to no connection with the disability community through my life and in many ways, didn’t even understand myself, and my own disability Things I thought odd details about myself – the way I jumped at loud noises, or struggled with understanding directions and finding my way around unfamiliar spaces– were all symptoms of my CP and I didn’t learn that until after I found Tonia’s blog. Through Tonia Says, I found community and understanding for the first time in my life, and that influenced my writing and the way I interacted with the world. I learned about disability history and culture. I learned about ableism and ways to advocate for myself. In short, Tonia Says changed my life and without her or her blog, I would have never connected with the disability community or claimed my own role in it. Because of Tonia, I am able to say I am a proud disabled woman.
Ellen Armendáriz Stumbo: I first met Tonia online. Someone sent her a link to a blog post I wrote, and we began talking. She was one of those people who, I believe, had a sixth sense that became attuned to know when parents of disabled kids needed a little extra hand holding in the journey. At least she did with me. Tonia made me a better parent. She confronted my ableism with grace, even when I know it took a lot of emotional labor for her to educate me. And I know she did it out of love. I don't know that any words could ever fully express the gratitude I feel for how she changed my life, and in turn, the lives of my kids. But also, she was my friend. We had a shared love of books and writing. She was much better at cheering me on than I was ever at cheering her on. Perhaps because she is the most prolific writer I’ve ever known, and I could not keep up with reading her work as fast as she wrote. And her stories are so real and authentically her. The disability representation that we all need. She was also a poet. Her emotions shared with a world through her written word, either through blog posts, her books, or her poems. And about her blog posts... talk about a wealth of wisdom and information for parents of disabled kids! She cared so much about us and our kids. That blog of hers was a guidepost in my life. Also, she had the best laugh. That big laugh that when I close my eyes, I can hear it! We spent Thanksgivings and Christmases and birthdays together. Sharing those laughs, talking about disability and books, talking about favorite characters from shows, and sometimes she would sing. Yup, if you know Tonia, you heard her sing at some point, probably a Disney tune or a song from a favorite musical. I miss her. Oh how I miss her. I was so fortunate to know her, and to call her my friend. I love you Tonia!
Emily Ball: I learned that it’s important that no matter what, it’s important to tell nondisabled people that you know more about your disability than they do.
I also learned about [place] blindness from her and that I have it. I’ve learned so much from her and I was eternally grateful for her.
I’ve been struggling with some things recently and I really wish she was here. I miss her.
Kayla Carlson: I met Tonia through a mutual friend, and honestly at first I was nervous because I’d seen some of her content, and was like “Oh, this person is way too cool to be my friend.” While I was totally right about her coolness level, she was such an amazing friend.
I can’t even begin to count the little moments where I was reading a blog post or one of her works where there was just the feeling of being completely understood. A feeling I’d experienced but never been able to put words to written on the page. It’s rare to be so seen, but I feel like Tonia really saw me in what was an unfortunately brief but incomparably meaningful friendship.
I told her I would leave a comment on every single chapter of the Disuphere Universe books she wrote, and even though I did, I just wish there was more.
She had so much to give to the world and the people she cared about. Even so, I’m glad the blog is still up for people to stumble upon. In fact, when a friend’s baby was discovered to have a disability, I offered her a link to Tonia’s blog to give her some insight. The friend found it so helpful to hear from someone who was actually disabled speaking on various disability related topics instead of the loud and all-too-prevalent nondisabled voices speaking on subjects they will never understand with the nuance and complexity a disabled person would.
I miss her. I love her. I thank her for her friendship. 💓
Alice Kina Diehl: Tonia Christle passed away this year. I miss her everyday. Thank goodness, her twin sister Tara Christle is still here. This small review sparked such a special friendship for years and ongoing. Film and Television is this important! 🤟🤟🤟
Amanda Diehl: Tonia was a safe space when I needed it most 💜
Emery: I think it’s impossible for someone to read Tonia’s blog and not learn from it, and it was also impossible to know Tonia and not learn something. And not just in a disability justice way. Tonia made damn sure that everyone she cared about learned that they were lovable and worth loving. I learned so much from Tonia’s painstaking line-by-line reviews of media, where, in the early days of our friendship, she and Tara called my attention to things I had completely missed in The Fosters’ terrible TBI storyline (aka the whole thing.) And in later years, I used [it] as a challenge to see how much I could “catch” on my own from the original content before reading the review.
I absolutely loved when Tonia shared stories about her own experiences, how she could combine What Parents Need To Hear™ with authentic disabled realness. I loved watching her writing evolve as she freed herself from the fawn response and started being even more honest, less afraid to speak her mind, and less concerned with being palatable to nondisabled people. I loved watching Tonia come into her power as she grew as a writer and a person. I felt honored that she chose to share so much of that with me as her friend and with all of us as the audience of her blog. I still feel like one of the best accomplishments of my life is that a conversation I had with Tara and Tonia over Marco Polo inspired a summer blog post series. I love that Tonia was willing to have complicated conversations about tough and potentially traumatic topics as a regular part of our friendship. I loved that she felt like my questions and our conversation were important enough to address more thoroughly and to share with others. And I loved the series that came out of that conversation - if you haven’t read it, you should check it out! I think the most incredible thing about Tonia’s blog is seeing the way she was able to connect to so many people with all of her different forms of writing. There was something for everyone: Poetry, media reviews, personal stories, interviews, hell, even product recommendations! Topics as far and wide as CP, trauma, disability community, childhood/growing up, advice, mental health, media representation, NaNoWriMo, and even illness and dying. Seeing comments on the blog or the Tonia Says Facebook page from regular readers who I didn’t know at all was such a wild experience - just knowing that Tonia was reaching all of these people, and I feel like the luckiest in the world to have really known her. Tonia taught me that I could take up space. That I matter. That it’s okay to ask for what I need. That it’s okay to need things - to need people. That she would always be there for me. All of that stuff is way more important than any book review.
Julie Idsinga: I love this 9th anniversary celebration, and have 2 posts in particular I keep thinking of, besides the beauty of getting to know Tonia herself.
One phrase that really stuck out to me, and has come back to me many times, I think came from Tonia's post about being in Costa Rica, with a little boy, and she said something along the lines of "Where everyone is disabled, nobody is."
Wow. Simple. And profoundly true. I could feel that feeling as I read it.
The other blog post series that spoke to me earlier, and again recently, was the series on unpacking "I can't".
I can relate to so much of it, and I hope professionals and parents can also read and learn from personal experiences and perspectives.
I love that Tonia openly shared her own experiences, but was also always clear and sensitive to the fact that her experiences and opinions were hers, and that all of us with Cerebral Palsy or other challenges may feel or experience the world differently.
There is so much more I could say about Tonia, and the impact she has had on my life... Her joy, her care for others, even while she was enduring so much, and her constant hope to make a positive impact on people's lives. She has... More than I can say.
You both have 💛💜
K: Tonia was—is—one of the most beautiful people I have ever known. She was the kind of friend who scrawled her phone number in the margin of her letter, even though her number was in my phone contacts already, just so I'd have it there ... just so I knew she was there. She was love, and light, and fire, with an incredible capacity for empathy and advocacy. She loved with a gentle fierceness, and I can still hear her laugh—can still hear the way she'd say, "Did you want to say more about that?" before we moved to a new conversation topic, because she wanted me to know that she was there to listen. I feel closest to her now when I read her words. One of my favorite blog posts of hers was her story about Nico--that embodied so much of what I love about Tonia, her perceptions, and her writing. She was the sister I never had as a child, and she loved and accepted every part of me—CP included. I love her. I miss her.
Alisa Marie: I’ve been struggling to know what to write for this.
Tonia showed me how to be comfortable with my human limitations. To accept myself as I am, without cleaning myself up first.
She taught me that all things that are different don’t need [to be] changed to fit the mold.
She taught me the power of being a cheerleader.
I miss her.
Kayla Rodriguez: Tonia. What [a] beautiful person to have graced this planet we all share. She was warmth and acceptance and the real definition of love. Her passion for words and advocating was something I watched proudly. Her work deserves so much praise and award. I know her legacy will live on in so many hearts.
She taught the world how to be still and listen for the heart. Something a chaotic, entitled culture does not do naturally. She showed how to gently love one another. To accept each other and not set expectations on one another.
I have referenced her series and her words to many people. It is my opinion that her series regarding faith and how it should look towards disabilities ought to be read by every single Christian that believes in the gift of healing. We need Tonia’s truth on the rejection that zealous faith causes to people with disabilities. I wish it weren’t needed, but alas it is. Her words broke my heart and opened my eyes in a way that I am ashamed to say they were not open before. I am thankful for her vulnerability and maturity to face such a grave horror and speak against it.
She was joy and liveliness! Her personality was so enjoyable. She could laugh and joke like no other. You could lose all track of time sitting next to her enjoying everything from cookies to deep discussions. Her affection was so sweet. Her hugs were warm and it felt like they healed the aching parts of your heart.
She was brave and courageous. I hope we can all be like her more. May her heart song continue to sing in the earth. She loved and lived so beautifully. Forever missed and forever adored.
Marissa Shefveland: Tonia was tenacious and did exactly what she set out to do through her words and stories. I was lucky enough to read her earliest stories and knew she had a gift. She always encouraged others and saw the best in everyone she met. I’m sad I let time and distance separate us, but I know she blessed many lives and is very loved and missed.
Vilissa Thompson: Knowing Tonia meant knowing another disabled person who loved words as much as I did.
Tonia was one of the first self-published disabled authors I found online, and getting to know her & Tara became a pleasant friendship.
Tonia was always excited to read whatever new piece I wrote, and celebrate the wins I was accomplishing in my work. That’s the kind of person she was - loving, warm, and incredible with words.
I miss hearing her write about a new blog post or one of her books she was drafting. I miss talking about favorite shows with her, or just her checking in to say hello. Tonia was the friend that was always there, from the good moments to the tough ones.
Tonia gave so much, and I hope she knew how loved and valued she was. She was truly amazing. I’m glad to have known her for almost a decade.
Tara: Tonia originally created Tonia Says because she hoped it would be a bridge between nondisabled parents and disabled children. But more than anything, I think she wished it could be a bridge to reach our parents in a meaningful way. So that they could truly see and understand her. As that hope gradually gave way, Tonia adapted. And Tonia Says became a safe haven where disabled people could come to experience being seen and understood. Sometimes, for the first time.
When Tonia Says began back in 2014, I didn’t believe I could claim a disabled identity. I’d been raised as a nondisabled child. I just thought I was really bad at it. But slowly, as I was exposed to her work, the work she shared by other people with disabilities, and most importantly, the disabled friendships she cultivated through this blog, I saw myself. And it healed a part of me that I didn’t know was broken to be able to own my disabilities. By accepting them some days, and other days railing against oppressive systems, people or representation. Some days, I was sad and disappointed by my limitations. And no matter what, Tonia would tell me “However you feel is okay.”
Over the years, Tonia has used Tonia Says and other platforms to create tangible change in disability representation in the media.
She reached out to an able-bodied actor who played a disabled character for years on network TV to gently explain why some disabled people disagreed with the casting of him in a disabled role. The actor understood and in years following, he said publicly that if a revival of the show took place, he would not reclaim his original role due to a need for authentic disabled casting.
Tonia’s tireless work pointing out the harmful disability representation in Seasons 4 and 5 of The Fosters led to the groundbreaking episode 5x11, “Invisible” in 2018. (Now available to stream on Hulu.) We saw scenes that centered the disabled character as someone with legitimate feelings and agency. The word “ableism” was said on TV for the first time we could recall. The TV parents apologized for the harm they did to their disabled teen and told him, “Honey, you’re not broken.” These showrunners and writers have gone on to create Good Trouble, with more nuanced disability storylines and authentic casting.
I loved how collaborating on this blog brought us together to discuss disability culture and pride, however I believe the work she was proudest of was the last installment of her disabled fiction series, called Quite Alive. Quite Alive delved into so many disability culture issues that we’d never seen represented before in a book. Things like disclosure, care dynamics, and personal accountability with ableist behaviors, to name a few. Quite Alive was the last longform work Tonia was able to complete, finishing it just days before her initial hospitalization to diagnose the illness that eventually took her life.
Tonia grieved as the losses piled on top of her mercilessly – pain control, mobility, writing, autonomy and ultimately life – and she also loved with such abandon, laughed and smiled, hugged and kissed.
Even in her last months when Tonia was unable to continue writing, she fought for the care and safety of herself and others. She was both scared and tenacious, both devastated and fierce, in the face of institutional harm and death.
In these last months, I’ve experienced both the earth-shattering loss of my twin, my soulmate, my favorite, and the feeling that she is just as close to me as she was in life.
Tonia, this is for you. A celebration of your life and your blog. A place to mourn this crater created by your absence. Both. I love you endlessly, and I hope you knew in life and continue to know now how incredible you are. Thank you for everything.


text:
Steal hearts of millions with your breathtaking personality by cladding into this charismatic pink color evening party wear designer gown. This indo-western style semi-stitched designer gown is made from georgette fabric and comes along with matching santoon inner. This designer gown is embellished with captivating embroidery work that gives a brilliant look to the outfit. Pair this designer georgette fabric gown along with danglers and pendants to create a bold style statement. The length of gown is around 50 to 52 inches and its bust size can be custom stitched upto 44 inches.
I was looking for some unique traditional party wear sarees blouse designs and party wear lehenga saree with price for my sister, stunned after seeing gorgeous collection of party wear sarees on your site


text:
Verizon Selling Some 700MHz Spectrum to U.S. Cellular
Jan 8, 2013, 11:31 AM by Eric M. Zeman
Verizon Wireless today announced that U.S. Cellular has agreed to purchase some of its 700MHz A Block spectrum licenses in Oklahoma City and 31 other counties throughout Oklahoma. In total, about 1.9 million POPs are covered by the licenses in question. Terms of the deal were not disclosed and it requires regulatory approval before it can be completed. Verizon agreed earlier this year to sell some of its 700MHz spectrum after the Federal Communications Commission gave it permission to purchase AWS spectrum licences from a consortium of cable companies.
Aug 10, 2022
Alongside its new foldable phones, Samsung has revealed its newest smartwatches and Bluetooth earbuds, each with significant engineering improvements. The new Galaxy Watch5 has a 13% larger battery and 60% more durable face compared to the Watch4.
Jan 17, 2024
While Samsung's big news today is the new S24 series of flagship phones, the company is also quietly launching two new affordable 5G phones today: the Galaxy A15 5G and Galaxy A25 5G. The Galaxy A15 5G updates last year's A14 5G with a 6.5-inch FHD+ AMOLED display with 90 Hz refresh, a major upgrade for a phone that sells for $200.
Jan 16, 2024
Motorola is launching a new version of its affordable moto g play phone for 2024. Last year's model was popular with carriers; this year's model appears to be just as popular, with AT&T, Verizon, Cricket, Consumer Cellular, U.S.
May 4, 2021
As part of its quarterly earnings report today, T-Mobile provided an update on its 5G rollout and Sprint customer migration. The company's faster "Ultra Capacity" 5G network — the bulk of which relies on 2.5 GHz mid-band radio frequencies — now covers 140 million people and is on track to cover 200 million by the end of 2021.
Jul 29, 2021
As T-Mobile continues to expand its 5G network, PCMag reports that the company has updated its coverage maps to differentiate between its faster "Ultra Capacity" 5G and its slower but more widely-available "Extended Range" 5G. T-Mobile's 5G Ultra Capacity network uses a mid-band frequency (2.5 GHz, AKA band 41, which was inherited from Sprint) that offers faster data speeds than most sub-6 GHz 5G, and much better coverage than mmWave 5G.

domain: news


text:
From October 9th to 22th 2017, specially in Buenos Aires. Some moments by Thomas Guillot.
Proposition for a collective discussion /The program asserts its nomadic character through its mode of operation, its status and its worldview, practising artistic research, understood as a tool for action and a probe for investigating worlds. /Its research agenda is by its very definition collective. Each member of the group is constituted as a practitioner […]


text:
Blue cylinder vase, Italian 1970s
This product is currently sold out.
Size: Height: 25 cm Diameter: 10 cm
Style note — homewares in the period between 1950s to 1970s were often produced in Modernist style. Defined by neat lines, bold and unusual colours and fairly minimalist shapes. All this often makes Modernist items very functional and timeless.
Facts of Lavish Did you know? There are no Import Duties on antiques into the USA, EU and many other countries — we do all the paperwork, you just enjoy the products.


text:
Stamps of Spain. Philately.
Protected Wildlife Stamps (Fauna Protegida) 2x0.54€ y 2x0.92€. Four endangered species of endangered Protected Wildlife series are presented for the first time, in a new sheet with stamped profiles of two of the species. Eagle owl, otter, bustard and imperial eagle.
World Heritage Sites - Segovia 2x1€ stamps. In 1985, the ancient city of Segovia and its Aqueduct were included by UNESCO in the list of World Heritage Sites. This commemorative, issue printed in intaglio and consists of a sheet with two stamps, plays an aerial view of the city. The philatelic values frame the Cathedral of Santa Maria and the famous...
Protected Wildlife Stamps (Fauna Protegida) 4x0.55€. Four endangered species of endangered Protected Wildlife series are presented for the first time, in a new sheet with stamped profiles of two of the species. Dragonfly, leatherback sea turtle, sturgeon and long-fingered bat.
Calcographic Test - 300 Years of Correos - Spain 2016. Limited edition dedicated to the philatelic subscriber. 300 Years of Correos (Spanish Postal Service) 1716-2016. Size 192 x 145 mm. In perfect condition, totally new (see pictures).
Star Wars - 40th Anniversary Stamp (Darth Vader) 5€. The design consists of a series of cartoons starring some of the characters in the films: Stormtrooper (Imperial Soldiers), Chewbacca, R2-D2, Yoda and C-3PO. Next to them, appears a seal that gathers an illustration of the villain of the saga, Darth Vader.
Star Wars - Han Solo: A Star Wars Story Stamp 5€. Pride of place on the new mini sheet goes to one of the most important characters in the movies, whose story is also told in his own prequel movie: Han Solo, his image is inevitably linked to his beloved ship, the Millennium Falcon, which appears on the mini sheet in the form of a sketch, with some of its...


text:
|Year : 2015 | Volume
| Issue : 2 | Page : 178-184
Comparison of levobupivacaine and levobupivacaine with fentanyl in infraumbilical surgeries under spinal anaesthesia
Joginder Pal Attri, Gagandeep Kaur, Sarabjit Kaur, Ravneet Kaur, Brij Mohan, Kamaljyoti Kashyap
Department of Anaesthesia, Government Medical College, Amritsar, Punjab, India
|Date of Web Publication||6-May-2015|
Joginder Pal Attri
Department of Anaesthesia, Government Medical College, Amritsar - 143 001, Punjab
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Intrathecal opioids added to low dose local anesthetics in spinal anaesthesia intensifies sensory block without affecting sympathetic blockade. Aim was to evaluate the safety and efficacy of intrathecal levobupivacaine plain versus levobupivacaine plus fentanyl in infraumbilical surgeries.
Materials and Methods: In a prospective randomized double blind study, 100 patients of American Society of Anesthesiologists grades I and II of either sex, 20-65 years of age were included after approval from the Ethics Committee. Informed consent was taken and patients were randomly divided into two groups of 50 each, to receive either 2 ml of 0.5% isobaric levobupivacaine (group L) or 2 ml of 0.5% isobaric levobupivacaine + 25 μg fentanyl (group LF) intrathecally. Patients were monitored for sensory and motor block characteristics, postoperative analgesia, haemodynamics and side effects and complications for 24 h.
Results: Onset of sensory block and time to maximum sensory block was rapid in group LF (4.8 ± 1.50 and 8.46 ± 1.87 min) as compared to group L (7.6 ± 1.46 and 15.80 ± 2.43 min) (P < 0.000). Maximum sensory block was T6 in group LF and T8 in group L. Maximum Bromage score was 2 in both groups but was achieved earlier in group LF (P < 0.000). Duration of sensory and motor block was significantly prolonged in group LF (270.98 ± 28.60 and 188.52 ± 9.81 min) as compared to group L (197.58 ± 11.20 and 152.76 ± 9.79 min). Total duration of analgesia was also prolonged in group LF (265.16 ± 26.18 min) as compared to group L (168.16 ± 11.08 min). Patients remained haemodynamically stable and side effects and complications were comparable in both groups. Data was analyzed using "Chi-square test" and "unpaired t-test."
Conclusion: Addition of fentanyl to levobupivacaine leads to early onset and prolonged duration of sensory and motor block as well as postoperative analgesia with stable haemodynamics and minimal side effects.
Keywords: Fentanyl, infraumbilical surgeries, levobupivacaine, local anaesthetics, spinal anaesthesia
|How to cite this article:|
Attri JP, Kaur G, Kaur S, Kaur R, Mohan B, Kashyap K. Comparison of levobupivacaine and levobupivacaine with fentanyl in infraumbilical surgeries under spinal anaesthesia. Anesth Essays Res 2015;9:178-84
|How to cite this URL:|
Attri JP, Kaur G, Kaur S, Kaur R, Mohan B, Kashyap K. Comparison of levobupivacaine and levobupivacaine with fentanyl in infraumbilical surgeries under spinal anaesthesia. Anesth Essays Res [serial online] 2015 [cited 2022 Dec 3];9:178-84. Available from: https://www.aeronline.org/text.asp?2015/9/2/178/152148
| Introduction|| |
Spinal anaesthesia is the most commonly used technique for infraumbilical surgeries because of its unmatchable reliability, cost effectiveness, effective analgesia, muscle relaxation and prolonged postoperative analgesia.  Recent advances in anesthesia has allowed more surgeries to be performed on day case basis.  The properties of an anaesthetic agent used for day case surgeries in spinal anaesthesia should have decreased incidence of anaesthesia related complications, should provide adequate postoperative analgesia and allow early patient discharge.  Levobupivacaine, a pure S(−) enantiomer of bupivacaine is a long acting amide local anesthetic which produces differential neuraxial block, that is, early onset and prolonged duration of sensory block with shorter duration of motor block and lower cardiac toxicity.  Levobupivacaine has been widely used in ambulatory surgeries after the development of low dose spinal anaesthesia technique. , To improve the block characteristics of intrathecally administered low dose local anaesthetics, addition of adjuvant is must. Intrathecal opioids enhance sensory block without prolonging motor and sympathetic block. , Among them, Fentanyl has rapid onset of action, binds strongly to plasma proteins and potentiates the afferent sensory blockade thus facilitates reduction in the dose of local anesthetics. , Literature is available where spinal block characteristics of plain levobupivacaine were compared with fentanyl as an adjuvant to decreased doses of levobupivacaine given intrathecally. ,,, The aim of the present study was to evaluate the safety and efficacy of equal doses of levobupivacaine plain (10 mg) and levobupivacaine (10 mg) plus fentanyl 25 μg, with respect to onset and duration of sensory and motor block, postoperative analgesia, hemodynamic parameters and side effects and complications in spinal anesthesia.
| Materials and methods|| |
In a prospective randomized double blind study, 100 patients of American Society of Anesthesiologists grades I and II of either sex, in the age group of 20-65 years scheduled for elective infraumbilical surgeries under spinal anesthesia were included after approval from the Institutional Ethics Committee. Patients with unwillingness for the procedure, coagulation or neurological disorders, septicemia, deformity or previous surgery of spine, morbid obesity, pregnancy and allergy to the study drug were excluded from the study. Informed written consent was taken from all the patients and were randomly divided into two groups of 50 each using a computer generated table of random numbers.
Group L (n = 50) received 2 ml of 0.5% isobaric levobupivacaine (10 mg) plus 0.5 ml normal saline and group LF (n = 50) received 2 ml of 0.5% isobaric levobupivacaine (10 mg) plus 0.5 ml fentanyl (25 μg) intrathecally. Total volume of the drug was kept constant as 2.5 ml in both groups to avoid bias during drug administration.
A day before surgery detailed preanaesthetic check-up was done. General physical examination along with proper systemic examination, assessment of airway and local examination of lumbar spine was done. Relevant investigations were reviewed. Visual analogue scale (VAS) was explained to the patients to determine the level of analgesia in the postoperative period. It was carried out with a 0-10 cm line. The first end mark "0" means "no pain" and the end marked "10" means "severe pain." Patients were asked to restrict solids and fluids by mouth at least 6 h before surgery.
On the day of surgery, patients were shifted to operation theatre after giving injection glycopyrrolate 0.2 mg intramuscularly 45 min before surgery. Multipara monitor was attached and baseline respiratory rate, heart rate (HR), noninvasive systolic and diastolic blood pressure (SBP and DBP), peripheral oxygen saturation and electrocardiography (ECG) were recorded and continuous monitoring was started. Intravenous (IV) line was secured with 18 gauge intracath and injection midazolam 0.04 mg/kg body weight was given IV. Patients were preloaded with 10 ml/kg body weight of Ringer lactate solution over 15-20 min. Under all aseptic precautions, spinal anaesthesia was given in L3 and L4 space with 25 gauge or 26 gauge Quincke spinal needle via midline approach in lateral decubitus position. On free flow of cerebrospinal fluid, study drug was injected intrathecally. In group L, 2 ml of 0.5% isobaric levobupivacaine plus 0.5 ml of normal saline and in group LF 2 ml of 0.5% isobaric levobupivacaine plus 0.5 ml fentanyl (25 μg) was given. Study drug was prepared in similar syringes keeping the drug volume constant by an anesthesiologist, who then handed over the syringe to another anaesthesiologist who performed the spinal block and also monitored all the patient variables. Patients were immediately turned to supine position and oxygen was started at the rate of 6 L/min. Continuous monitoring of respiratory rate, HR, noninvasive SBP and DBP, SpO 2 and ECG was done at 0 min, 3 min and 5 min, then at an interval of every 5 min up to 30 min and then every 15 min till the end of surgery. Bradycardia (defined as HR <60 bpm) was treated with injection atropine sulphate 0.6 mg IV. Hypotension (defined as fall in SBP >20% from baseline) was treated with additional Ringer's lactate solution and injection ephedrine 5 mg IV titrated according to blood pressure.
Sensory block was assessed by loss of sensation to pin prick in the midline every 2 min for first 10 min and then at an interval of 5 min till no change in level occurred. Onset of sensory block (when patient does not feel pin prick at T10 level), highest level of sensory block achieved, time to maximum sensory block, regression of sensory block to T10 and total duration of sensory block (regression to S1 dermatome) was noted.
Motor block was assessed by using the modified Bromage scale,  every 2 min up to 20 min and then at an interval of 10 min till the completion of surgery. Modified Bromage scale was taken as: 0 - No paralysis: Able to flex hips/knees/ankles, 1 - able to move knees, unable to raise extended legs, 2 - able to flex ankles, unable to flex knees, 3 - unable to move any part of limb - complete block. Maximum motor block achieved, time to maximum motor block and total duration of motor block (motor recovery to Bromage  was noted. All parameters were noted by taking the time of giving the study drug intrathecally as time 0. Surgery was allowed to start when sensory block to T10 dermatome was achieved. During intraoperative period, if any patient felt pain then injection ketamine was given IV as supplementary analgesia. It was repeated twice and if adequate analgesia was not achieved then patients were given general anaesthesia and were excluded from the study. The quality of surgical analgesia was assessed and graded as: Excellent - No supplementary drugs required, good - Analgesic required, fair - More than one analgesic required, poor - General anesthesia required.
In the postoperative period, patients were monitored for haemodynamic parameters and postoperative using VAS score, every 15 min for 120 min, then half hourly for 180 min, hourly for 12 h and thereafter every 3 hourly till 24 h of surgery in both groups. Rescue analgesia in the form of injection diclofenac 75 mg or if needed injection tramadol hydrochloride intramuscularly was given when VAS >3 in both groups. Time at which patient demanded first dose of rescue analgesia was taken as total duration of analgesia. Number of doses of rescue analgesia required in the postoperative period was also noted. Patients were monitored for any side effects or complications like hypotension, bradycardia, nausea, vomiting, sedation, urinary retention, pruritis, headache, backache and neurological changes for 24 h.
At the end of the study, patient satisfaction score was generated by general questioning of the patients regarding their experience of anesthesia during intra- and post-operative period. It was analyzed as: 5 - Very satisfied, 4 - satisfied, 3 - neutral, 2 - dissatisfied, 1 - very dissatisfied.
Power analysis was done. Effective size/power of the study was determined by taking in to account the mean onset of sensory block, mean duration of sensory block and total duration of analgesia. The power was well above 90% by taking α error 0.05. The data from the present study was systematically collected, compiled and statistically analyzed using software IBM SPSS 17.0 (IBM Chicago SPSS Inc) to draw relevant conclusions. Data was expressed as mean and standard deviation, number and percentages. The patient characteristics (nonparametric data) was analysed using the "Chi-square tests" and the inter group comparison of the parametric data was done using the "unpaired t-test." The P value was finally determined to evaluate the level of significance. P < 0.05 was considered as significant at 5% significance level; P < 0.01 was considered significant at 1% significance level and P < 0.001 was considered highly significant.
| Results|| |
In the present study, both groups were comparable with respect to demographic characteristics, baseline haemodynamic parameters and duration of surgery as shown in [Table 1]. Surgical procedures performed on patients in both groups were comparable. Most commonly performed surgery was inguinal hernia repair [Table 2]. After administering the study drug intrathecally, the mean time taken for onset of sensory block to T10 dermatome and the time to maximum sensory block in group L was more as compared to group LF and the difference was highly significant (P = 0.000). However the median maximum sensory level reached in group L was T8 dermatome and in group LF was T6 dermatome. Median maximum motor block achieved in both the groups was Bromage 2. But the mean time taken for achieving Bromage 2 motor block was more in group L as compared to group LF and the difference was highly significant (P = 0.000). Regression of sensory block to T10 dermatome was significantly prolonged in group LF (106.62 ± 6.17 min) when compared to group L (95.58 ± 5.32 min) (P = 0.000). The total duration of sensory block (regression of sensory block to S1 dermatome) and total duration of motor block was also significantly prolonged in group LF as compared to group L (P = 0.000). Motor and sensory block parameters are shown in [Table 3].
|Table 3: Sensory and motor block characteristics in group L and group LF|
Click here to view
Visual analog scale score was used to monitor the patients for postoperative pain. VAS was 0 at 90 min of the study period then it started increasing in both the groups. VAS was on higher side in group L as compared to group LF till 180 min. (P = 0.000) and patients demanded first dose of rescue analgesia at 180 min. After this interval, VAS was on significantly higher side in group LF (P = 0.000) and patient demanded first dose of rescue analgesia at 5 th h of the study period as shown in [Figure 1]. Hence duration of analgesia was significantly prolonged in group LF (265.16 ± 26.18 min) as compared to group L (168.16 ± 11.08 min), (P = 0.000). The total number of doses of rescue analgesia required in 24 h was also significantly less in group LF as compared to group L (P = 0.000) [Table 3]. Quality of surgical analgesia was excellent in both groups as none of the patient required supplementary analgesia intraoperatively.
|Figure 1: Line diagram showing mean visual analog scale (VAS) scores in group L and group LF. Mean VAS score at various time intervals. VAS was 0 and comparable for 90 and 105 min in both groups. VAS started increasing in group L and was >3 at 180 min and patient demanded first dose of rescue analgesia. In group LF, VAS was >3 at 5th h and first dose of rescue analgesia was given. Group LF required less number of doses of rescue analgesia as compared to group L. P =0.001. Group L: Levobupivacaine, Group LF: Levobupivacaine + fentanyl|
Click here to view
Patients were monitored for hemodynamic parameters at various time intervals starting from baseline till 24 h. There was no significant change in HR from baseline in both the groups throughout the study period. Five patients (10%) in group LF and two patients (4%) in group L (P = 0.24) developed bradycardia during initial 10-15 min interval intraoperatively for which injection atropine sulphate was given. Mean doses of atropine given in group LF was 1.7 mg and in group L was 1 mg. SBP and DBP also remained stable and comparable throughout the study as shown in [Figure 2]. In group L, 4 (8%) patients and in group LF, 6 (12%) patients (P = 0.50) had fall in SBP during 10-15 min interval intraoperativety and the percentage fall in SBP and DBP at 10 and 15 min was also comparable in both groups. Oxygen, addition IV fluids and injection ephedrine was given for treating hypotension. Total dose of ephedrine given in two groups was comparable, in group L was 15 mg and in group LF was 20 mg. Respiratory rate and SpO 2 was monitored and remained stable and comparable and none of the patient developed respiratory depression in both groups.
|Figure 2: Mean heart rate (HR), systolic blood pressure (SBP) and diastolic blood pressure (DBP) in group L and group LF intraoperatively. Mean HR, SBP and DBP at various time intervals. Vitals remained stable and comparable at all intervals. Five patients (10%) in Group LF and two patients (4%) in Group L developed bradycardia, (P = 0.24). Four (8%) patients in Group L and 6 (12%) patients in Group LF (P = 0.50) had fall in SBP. Group L: Levobupivacaine, Group LF: Levobupivacaine + fentanyl|
Click here to view
Patients were monitored for side effect and complications for 24 h. None of the patient had nausea and vomiting, headache or backache in the postoperative period. Four (8%) patients in group LF had pruritis in the postoperative period whereas none of the patient in group L had pruritis. (P = 0.04). Incidence of urinary retention in group LF was 6% (3 patients) and in group L, urinary retention was not reported in any patient (P = 0.07). At the end of the study, patient satisfaction score was comparable (in group L: 4.63 ± 0.67 and in group LF: 4.67 ± 0.66; P = 0.847) in both the groups as patients were satisfied with anaesthesia and analgesia in both groups.
| Discussion|| |
Spinal anaesthesia is a commonly used technique for infraumbilical surgeries, as it provides faster and effective onset of sensory and motor block and prolonged postoperative analgesia.  Levobupivacaine is a preferred local anaesthetic due to its longer sensory block, lower cardiac and central nervous system toxicity and shorter motor block. It produces localized anesthesia by blocking the transmission of action potential in sensory, motor and sympathetic nerve fibers, by inhibiting the passage of sodium through voltage sensitive ion channels in the neuronal membrane.  The duration of action of levobupivacaine is dose dependent and it was found that 10 mg is the minimum dose for effective sensory and motor block in spinal anesthesia.  Intrathecal opioids as an adjuvant to low dose local anesthetics, produces a synergistic effect by acting directly on the opioid receptors in the spinal cord.  Fentanyl, stimulates both μ1 and μ2 receptors and potentiates the afferent sensory blockade.  Studies reported that addition of 25 μg fentanyl to LA improves anesthesia quality and prolongs postoperative analgesia without prolonging the time to void.  Inspired by the above findings, we selected 10 mg dose of levobupivacaine and compared it with 10 mg levobupivacaine plus 25 μg fentanyl given intrathecally for spinal block characteristics.
The results of the present study demonstrated that addition of fentanyl to levobupivacaine improves the sensory and motor block characteristics, prolongs postoperative analgesia with decreased requirement of rescue analgesics in the postoperative period, without increasing the incidence of side effect and complications.
In the present study, time to onset of sensory block and the time to achieve maximum sensory and motor block was more rapid, the duration of sensory and motor block and postoperative analgesia was more prolonged in levobupivacaine and fentanyl group as compared to plain levobupivacaine group. Maximum sensory level in group L was T8 and in group LF was T6 dermatome but the maximum motor block was Bromage 2 in both groups. Requirement of postoperative rescue analgesics was also less in group LF.
Ozyilkan et al.,  compared 2.2 ml of levobupivacaine plain with 10 μg fentanyl or 2.5 μg sufentanil as adjuvant in spinal anesthesia for caesarean section. Onset of sensory and motor block was achieved more rapidly in fentanyl and sufentanil group (P < 0.001). Duration of sensory and motor block and time for first analgesic requirement was longer in adjuvant groups as compared to plain group (P < 0.001). Akan et al.  while using 10 mg plain levobupivacaine and comparing it with 7.5 mg levobupivacaine plus 25 μg fentanyl and 7.5 mg levobupivacaine plus 2.5 μg sufentanil in patients undergoing transurethral resection of the prostate under spinal anaesthesia concluded that combining lower doses of levobupivacaine with fentanyl and sufentanil provides faster onset of sensory block, lower frequency and shorter duration of motor block and prolonged analgesia time. However in the present study, motor block duration was prolonged in group LF as compared to group L. This difference might be due to the use of equal doses of levobupivacaine in both groups. Cuvas et al.,  also added 15 μg fentanyl to lower dose of levobupivacaine 2.3 ml and compared it with 2.5 ml of plain levobupivacaine. The time to onset of sensory and motor block, regression of sensory block to S1 was similar in both groups. Duration of motor block was shorter in fentanyl group. Again the dose of levobupivacaine used was less in this group. Addition of fentanyl to levobupivacaine resulted in higher sensory level (T6) as compared to plain levobupivacaine (T9) which was almost similar to the findings of the present study (T6 in group LF and T8 in group L). The difference in the level of sensory block in both the groups can be explained by the difference in the baricity of the injected solutions. Opioids are hypobaric and when added to hypobaric LA will make the mixture more hypobaric thus altering the density of resulting solution which effects the direction and extent of spread in spinal block. Girgin et al.,  while using 5 mg levobupivacaine plus 25 μg fentanyl and 7.5 mg levobupivacaine plain demonstrated that maximum sensory level was T7 and T6 respectively; however the maximum motor block achieved was Bromage 2 in both groups. In this study maximum sensory level achieved was lower in combination group which might be due to the low dose of levobupivacaine used in this group.
Heart rate and blood pressure remained stable and comparable in both the groups intraoperatively as well as postoperatively. Bradycardia was observed in 5 (10%) patients in group LF and 2 (4%) patients in group L and hypotension was seen in 4 (8%) patients in group L and 6 (12%) patients in group LF. Similar findings were reported by a previous study, where incidence of bradycardia was 15% when 10 mg of levobupivacaine was given intrathecally.  Chattopadhyay et al.  concluded that addition of fentanyl to levobupivacaine does not increase the incidence of bradycardia. Akan et al.  also concluded that there was no significant difference in the mean heart and blood pressure in plain levobupivacaine group and levobupivacaine plus fentanyl group. Similar results were reported by Cuvas et al.  and Lee et al.
The most common side effect observed with intrathecal fentanyl was pruritus which was observed in 4 (8%) patients in group LF and none in group L (P = 0.004). Pruritus as a side effect of intrathecal fentanyl was reported by previous studies also. ,, Second most commonly occurring side effect of spinal anaesthesia is delayed micturition. With addition of 25 μg fentanyl to 5 mg levobupivacaine, Girgin et al.  did not reported urinary retention in any patient. In the present study, only 3 (6%) patients in group LF and none of the patient in group L had delayed micturition but the difference was statistically nonsignificant. No other side effect and complications were observed in both the groups. Patients were satisfied with the surgical analgesia and postoperative analgesia in both the groups. Similar patient satisfaction scores were reported by Lee et al.  and Cuvas et al.
Limitation of our study was that we did not compare the two groups for achieving home discharge criteria. Hence, we were not able to evaluate the effect of fentanyl added to levobupivacaine on the recovery profile of patients from spinal block.
| Conclusion|| |
Both regimes were effective in providing surgical anaesthesia and haemodynamic stability, but group LF offered an advantage of rapid onset of sensory and motor block and prolonged duration of sensory block and postoperative analgesia, thus decreasing the doses of rescue analgesia in the postoperative period. However, prolonged motor block was unwanted as it delays early ambulation.
| References|| |
Casey WF. Spinal anaesthesia - A practical guide. Update Anaesth 2000;12:1-7.
Hadzic A, Karaca PE, Hobeika P, Unis G, Dermksian J, Yufa M, et al.
Peripheral nerve blocks result in superior recovery profile compared with general anesthesia in outpatient knee arthroscopy. Anesth Analg 2005;100:976-81.
Redmond M, Florence B, Glass PS. Effective analgesic modalities for ambulatory patients. Anesthesiol Clin North America 2003;21:329-46.
Foster RH, Markham A. Levobupivacaine: A review of its pharmacology and use as a local anaesthetic. Drugs 2000;59:551-79.
Girgin NK, Gurbet A, Turker G, Bulut T, Demir S, Kilic N, et al.
The combination of low-dose levobupivacaine and fentanyl for spinal anaesthesia in ambulatory inguinal herniorrhaphy. J Int Med Res 2008;36:1287-92.
Onur O, Sibel AM, Mustafa A, Mehmet Y. Comparison of the effects of intrathecal different dosage of levobupivacaine in elective day-case arthroscopy of the knee. Middle East J Anaesthesiol 2010;20:703-8.
Wang C, Chakrabarti MK, Whitwam JG. Specific enhancement by fentanyl of the effects of intrathecal bupivacaine on nociceptive afferent but not on sympathetic efferent pathways in dogs. Anesthesiology 1993;79:766-73.
Ben-David B, Solomon E, Levin H, Admoni H, Goldik Z. Intrathecal fentanyl with small-dose dilute bupivacaine: Better anesthesia without prolonging recovery. Anesth Analg 1997;85:560-5.
Janicki PK, Parris WE. Clinical pharmacology of opioids. In: Smith HS, editor. Drugs for Pain. Philadelphia: Hanley and Belfus; 2003. p. 97-118.
Goel S, Bhardwaj N, Grover VK. Intrathecal fentanyl added to intrathecal bupivacaine for day case surgery: A randomized study. Eur J Anaesthesiol 2003;20:294-7.
Cuvas O, Basar H, Yeygel A, Turkyilmaz E, Sunay MM. Spinal anesthesia for transurethral resection operations: Levobupivacaine with or without fentanyl. Middle East J Anaesthesiol 2010;20:547-52.
Akan B, Yagan O, Bilal B, Erdem D, Gogus N. Comparison of levobupivacaine alone and in combination with fentanyl and sufentanil in patients undergoing transurethral resection of the prostate. J Res Med Sci 2013;18:378-82.
Krobot R, Bacak I, Premuzic J. Levobupivacaine-fentanyl spinal anaesthesia for transurethral urologic surgery. Eur J Anaesthesiol 2005;22:899-903.
Guler G, Cakir G, Ulgey A, Ugur F, Bicer C, Gunes I, et al
. A comparison of spinal anaesthesia with levobupivacaine and hyperbaric bupivacaine for caesarian sections: A randomized trial. Open J Anesthesiol 2012;2:84-9.
Dizman S, Turker G, Gurbet A, Mogol EB, Turkcan S, Karakuzu Z. Comparison of two different doses of intrathecal levobupivacaine for transurethral endoscopic surgery. Eurasian J Med 2011;43:103-8.
Scott PV, Bowen FE, Cartwright P, Rao BC, Deeley D, Wotherspoon HG, et al.
Intrathecal morphine as sole analgesic during labour. Br Med J 1980;281:351-3.
Honca M, Dereli N, Kose EA, Honca T, Kutuk S, Unal SS, et al
. Low-dose levobupivacaine plus fentanyl combination for spinal anesthesia in anorectal surgery. Rev Bras Anestesiol 2014. Available from http://dx.doi.org/10.1016/j.bjane.2014.01.007
. [Last accessed on 2015 Jan 01].
Ozyilkan NB, Kocum A, Sener M, Caliskan E, Tarim E, Ergenoglu P, et al
. Comparison of intrathecal levobupivacaine combined with sufentanil, fentanyl or placebo for elective caesarian section: A Prospective, Randomized, Double-Blind, Controlled Study. Curr Ther Res Clin Exp 2013;75:64-70.
Chattopadhyay S, Halder B, Saha GC, Karmakar S. Comparison of two concentrations of isobaric intrathecal levobupivacaine for vaginal hysterectomy. Indian J Pain 2013;27:154-7.
Lee YY, Muchhal K, Chan CK, Cheung AS. Levobupivacaine and fentanyl for spinal anaesthesia: A randomized trial. Eur J Anaesthesiol 2005;22:899-903.
Akcaboy EY, Akcaboy ZN, Gogus N. Low dose levobupivacaine 0.5% with fentanyl in spinal anaesthesia for transurethral resection of prostate surgery. J Res Med Sci 2011;16:68-73.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]
|This article has been cited by|
||Safety and effectiveness of adding fentanyl or sufentanil to spinal anesthesia: systematic review and meta-analysis of randomized controlled trials
| ||Neuber Martins Fonseca, Gabriel Magalhães Nunes Guimarães, João Paulo Jordão Pontes, Liana Maria Tores de Araujo Azi, Ricardo de Ávila Oliveira |
| ||Brazilian Journal of Anesthesiology (English Edition). 2021; |
|[Pubmed] | [DOI]|
||Efficacy of intrathecal fentanyl versus buprenorphine as an adjuvant to isobaric levobupivacaine in lower limb surgeries: a comparative study
| ||PreetHiten Furia, VasantiMukund Sasturkar, SanhitaJ Kulkarni, PradnyaShripad Joshi, PramodV Bhale |
| ||MGM Journal of Medical Sciences. 2021; 8(4): 336 |
|[Pubmed] | [DOI]|
||Comparison of a Combination of Caudal Levobupivacaine with Fentanyl and Levobupivacaine Alone for Alleviating Postoperative Pain During Infraumbilical Procedures in Children Under 3 Years
| ||Muralidar Vakkapatti,Thrivikram Shenoy,Sonal Bhat |
| ||The Open Pain Journal. 2019; 12(1): 19 |
|[Pubmed] | [DOI]|
||Comparison between Clinical Efficacies of Levobupivacaine Plain and Levobupivacaine with Fentanyl for Urological Surgeries under Subarachnoid Block
| ||Aarti Kulkarni,Paulomi Dey |
| ||Journal of Research & Innovation in Anesthesia. 2017; 2(2): 34 |
|[Pubmed] | [DOI]|
||COMPARATIVE STUDY OF INTRATHECAL LEVOBUPIVACAINE-FENTANYL AND LEVOBUPIVACAINE IN CAESAREAN DELIVERIES
| ||Wasudeo Sadashio Barsagde,Naresh Ganapat Tirpude,Kamlesh Sarangdhar Pillewan |
| ||Journal of Evidence Based Medicine and Healthcare. 2017; 4(23): 1305 |
|[Pubmed] | [DOI]|


text:
The way you run your morning can shape your entire day. From the food you eat to the way you put on your workwear armory; the things you do can have a big impact on the success of your day.
Even busy female professionals can create a morning routine for success without it taking up more time than you have to spare. Read on to find out how…
SET THAT ALARM FOR EARLIER
Try getting up a little bit earlier every single morning, even if it’s just by 15 minutes. Those extra minutes could do wonders for your morning routine for success and allow you to get more done before you even leave the house.
Studies have shown that the earlier you wake up, the more time your brain has to get into gear and get you ready for the day!
THINK ABOUT THE FUTURE
You may have heard it’s about mindfulness, but really, a brief reflection before you get out of bed is a great way to center yourself for the day ahead. Think about what you achieved the day before and what your plans are for today.
Frame the work positively, and think about your goals and aspirations both in the short and long term. This only needs to take a few minutes and can even be done while you’re in the shower or on your commute. Find out the habits of happy people here.
GET ENOUGH PROTEIN
Breakfast is the most important meal of the day! And while we don’t always have time to linger and savor it, the right ingredients can ensure you get an early morning boost of protein, fiber, and vitamins.
Need some inspiration? Check out our 7-day meal plan here.
START THE DAY WITH A SIMPLE TASK
The simplest task that takes a couple of seconds, making your bed can completely change your mindset for the day. As the old saying goes: ‘Tidy space, tidy mind’. Get some inspiration on how successful women organize their homes here.
MAKE A LIST
Whether you physically write it down or make a list on your phone, write down everything you want to do in the day. Not only will it help you remember it, but it’ll get any worries or concerns about the goal out of your head and into the world.
Want to know how to use a planner to be successful, click here.
DETOX FROM SOCIAL MEDIA
It can be ever so tempting but try not to use your phone until you’ve done your morning routine for success. Leave emails for the office and don’t go on social media as soon as you wake up – it can affect your mood before you’ve even gotten out of bed!
ENJOY SOME COMFORT
Whether it’s a specialty coffee or the perfect cup of tea, there’s always some time to indulge in something warm and delicious. This feeling of coziness, coined as hygge by the Danes, can vastly improve your mood and make sure you’re feeling positive all day long.
DO AS THE CEOS DO
Many CEOs say they try to read at least ten pages of a book a day to continuously learn. For busy women, apps like Audible, BookBeat or other audiobook providers mean you can listen while you do other things. There are even apps that digest non-fiction tomes into five-minute reads. Read a little, gain a lot.

domain: psychology


text:
|Picture of Bakewell by Maria Smith|
Regular readers of the blog will know I pack as much fun as I can into my break from the working week. I've learnt the hard way, that as with everything in life, planning is absolute key if you want to make the most of every minute. So plan!
We're almost into May, and I've decided my priorities for the coming month, will include getting out and about as much as I can, in and around my local area. I'm lucky enough to live within easy driving distance of beautiful Derbyshire. I've visited before but there are many new places I'm yet to discover.
I enjoy getting out with my camera, snapping pictures of the wonderful landscape, magnificent houses, beautiful flowers, and anything else that appeals.
I'll be going back to some of my favourite places. Including Calke Abbey and Kedleston Hall as well as visiting more of the Peake District where there is lots more to explore over the coming months.
|Picture of Calke Abbey by Maria Smith|
What plans are you making for the weekend?

domain: geography


text:
GREETING CARD WITH BLANK INTERIOR
SIZE: 4.25 x 5.5 in
There is no better friend than a sister. You two make the world a better place! Let your sister know how you feel with the "Sisters" card. Printed illustration on luxury white linen stock with pattern backing. Printed professionally with blank interior and made in Canada. Envelopes are green-e certified, FSC certified and green seal certified.


text:
Patricia Snyder con A Primer for Widowhood (English Edition)
Laced with comfort and humor, Primer is a useful and practical guide, a tender, personal instruction manual for beginning a life alone. Each essay is a ladder with strong rungs, lifting the surviving spouse out of the morass of grief and sadness into a place of purpose, direction and hope for the future. The constant theme is survival, vowing to live with grace and courage in the face of devastating tragedy. As widows, we belong to a sisterhood, a bond forged by a life-changing event. Although we begin as strangers, we will come to know each other because of the experience we share. Primer will be a constant companion for the next among us to be called widow.

domain: library


The North Face Boy's Reversible Off The Grid Fleece Jacket
The North Face Reversible Off the Grid Fleece Jacket doubles your boy's options for staying warm, depending on which side he feels like sporting for the day. Constructed with midweight cozy fleece, and the addition of reinforced shoulders helps to keep the chill away. It's like the ultimate BOGO - so keep your boy warm and comfortable with this versatile fleece jacket.
- The North Face
- Fully reversible jacket with gridded fleece Zip hand pockets on outer Welt pockets on reverse Heat transfer logo on front of outer Embroidered logo on reverse
- Tech Specs
- Body: 50D 275 g/m² 100% polyester gridded fleece Overlay: 73 g/m² 100% recycled polyester taffeta Weight: 375 g (13.2 oz)


Having been long teased for Nintendo Switch Online, the GoldenEye 007 Switch port finally has a release date.
A well-loved Nintendo 64 classic, GoldenEye 007 was revealed to be heading to Nintendo Switch as part of the Nintendo Switch Online + Expansion Pack subscription. The game joins a line-up of iconic 90's titles, including: The Legend of Zelda: Ocarina of Time, Mario Kart 64 and Banjo-Kazooie.
Way back in Nov. 2021, players were alerted to a possible port after the game was unbanned in Germany. Nintendo's European eShop is based in Germany, and any game that is to be sold to the European market has to pass the country's checks. Almost a year later, Nintendo announced that the port would finally be coming to Nintendo Switch.
Earlier today, Nintendo specified exactly when we'd all be reunited with GoldenEye 007 and it just so happens to be very soon.
GoldenEye 007 Nintendo Switch Online Release Date
GoldenEye 007 will be available to play as part of the Nintendo Switch Online + Expansion Pack subscription on Jan. 27, 2023.
The game will also feature an online multiplayer mode, available on the same day as the port's release.