What is delta bilirubin?

•

24 likes•24,406 views

Basic concepts regarding delta bilirubin are presented.

What is delta bilirubin?
by

Dr. Ketan Vagholkar
MS, DNB, MRCS, FACS
Consultant General Surgeon

$Delta Bilirubin  Glucoronides are chemically reactive metabolites.  In adults, with prolonged cholestasis especially if it is accompanied by renal failure, a fraction of the bilirubin conjugates readily non enzymatic ally and irreversibly with serum albumin to give yellow billiproteins in which bilirubin is covalently bound to albumin.  This fraction increases with the duration of cholestasis and is designated as delta bilirubin.$

Delta bilirubin

 Delta bilirubin retains its direct reading properties.
 As delta bilirubin is irreversibly bound to albumin it is
not filtered at the glomerulus and its half life reflects that
of albumin.(14 days)
 Consequently it remains in plasma long after other
bilirubin esters have been eliminated giving rise to
conjugated hyperbilirubinemia in the absence of
bilirubinuria and is particularly evident in the recovery
phase of cholestasis.
 Delta bilirubin= Total bilirubin-(Conjugated +
Unconjugated bilirubin)

What's hot

Liver function tests and interpretation

subramaniam sethupathy

Laboratory Diagnosis of Jaundice

Dr. Varughese George

RENAL FUNCTION TESTS (RFT)

YESANNA

Liver Function Tests

DJ CrissCross

GFR ,plasma load,clearence,ACR,CCR,eGFR by dr.Tasnim

dr Tasnim

Jaundice - Liver Function Tests

Tapeshwar Yadav

Ascitic fluid analysis

Muhammad Asim Rana

Approach to lft

Abhinav Srivastava

It is characterized by a yellow appearance of the (1) Skin (2) Mucous membranes and (3) Sclera caused by bilirubin deposition. It is the most specific clinical manifestation of Hepatic dysfunction. Jaundice is usually present clinically when the plasma bilirubin concentration reaches 2 to 3 mg/dl. When bilirubin clearance from the Liver to the Intestinal tract is impaired (as in acute hepatitis and bile duct obstruction) it may be accompanied by alcoholic (Gray coloured) stools.Solubility increases in water , soluble conjugated bilirubin leads to Tea coloured urine.

Metabolism of bilurubin

Tapeshwar Yadav

LIVER FUNCTION TESTS (LFT)

YESANNA

D dimer test and sample collection procedure

anjalatchi

Chronic Myeloid Leukemia

docaneesh

Ascitic fluid examination

Bahria University Medical & Dental College, Karachi, Pakistan

Glycated haemoglobin ppt by Basalingappa BG

BASALINGAPPA GUTTEDAR

Total iron binding capacity

School of science

Estimation of iron profile

Sk. Mizanur Rahman

Renal Function Tests (RFTs)

ShibleeZaman

Non alcoholic steatohepatitis copy

Keshri Yadav

Hemolytic anemia

Abhinav Srivastava

creatinine

MLT LECTURES BY TANVEER TARA

What's hot (20)

Liver function tests and interpretation

Laboratory Diagnosis of Jaundice

RENAL FUNCTION TESTS (RFT)

Liver Function Tests

GFR ,plasma load,clearence,ACR,CCR,eGFR by dr.Tasnim

Jaundice - Liver Function Tests

Ascitic fluid analysis

Approach to lft

Metabolism of bilurubin

LIVER FUNCTION TESTS (LFT)

D dimer test and sample collection procedure

Chronic Myeloid Leukemia

Ascitic fluid examination

Glycated haemoglobin ppt by Basalingappa BG

Total iron binding capacity

Estimation of iron profile

Renal Function Tests (RFTs)

Non alcoholic steatohepatitis copy

Hemolytic anemia

creatinine

Viewers also liked

Bilrubin & jaundice: causes,pathogenesis,classification & clinical features

Mohammad Manzoor

Bc prac

Aheed Khan

Barium Meal study

dr.unni1980

Rntcp and national strategic plan(nsp) for tb

Wal

Physiological jaundice

Nirsuba Gurung

Bilirubin prc

justingnanou

Liver

Medical Students

Liver anatomy, physiology and imporatance to anesthesia

Dr. Priyanka Shah

Tb management 2016

Haripriya Uppala

Clinical approach to jaundice

Karthika Ramadoss

Hyperbilirubinemia

Jackie San

The Business Case for Corporate Performance Management

Charles Bedard

2011-2012 Slumber Parties Catalog

SlumberPartiesByConnieM

Viewers also liked (13)

Bilrubin & jaundice: causes,pathogenesis,classification & clinical features

Bc prac

Barium Meal study

Rntcp and national strategic plan(nsp) for tb

Physiological jaundice

Bilirubin prc

Liver

Liver anatomy, physiology and imporatance to anesthesia

Tb management 2016

Clinical approach to jaundice

Hyperbilirubinemia

The Business Case for Corporate Performance Management

2011-2012 Slumber Parties Catalog

Similar to What is delta bilirubin?

Bililrubin

Bilirubin metabolism

Bilirubin

Bilirubin

Jaundice

Bilirubin estimation

Ictericia5

HEME DEGRADATION

Bilirubin 1

Bilirubin metabolism, Hemolytic anemia-classification and lab diagnosis.pptx

MohammedAsif793577

dr gurjinder bilirubin estimation.pptx

gurjinder singh

Liver function tests

International Medicine School - Management and Science University

Bilirubin metabolism

DrVeereshDhanni

Bilirubin Metabolism Rajendra

Rajendra Dev Bhatt

LIVER FUNCTIONS TESTS -1-

International Medicine School - Management and Science University

Bilirubin is a biochemical parameter of your liver function test. Your doctor uses this tool to diagnose liver disease. In the human body, bilirubin is a waste product of your hemoglobin produced during the red blood cells breakdown in the spleen. Although bilirubin does not have a specific function, it is generally a component of bile juice. It is also called a bile pigment, which is yellow in color. There are two forms of bilirubin in our blood. One is unconjugated bilirubin, which forms during the breakdown of red blood cells, and the other is conjugated, which starts during metabolism in the liver. The unconjugated bilirubin is a catabolic product of red blood cells. This non-conjugated compound is also known as indirect bilirubin. Some possible reasons or diseases associated with unconjugated hyperbilirubinemia – 1. Hemolytic anemia 2. Neonatal Jaundice 3. Genetic factors 4. Drug induced unconjugated hyperbilirubinemia On the other hands, Conjugated bilirubin is generally formed after the glucuronidation of the unconjugated bilirubin. The conjugation process occurs in your liver and converts your unconjugated bilirubin into conjugated bilirubin. This type of glucuronidation compound is also known as direct bilirubin. In simple words, direct bilirubin means conjugated bilirubin. The elevated conjugated bilirubin indicates Conjugated hyperbilirubinemia. This condition is most commonly seen in cholestatic liver disease. Cholestatic is a medical condition where the flow of bile juice gets reduced or stopped. You may have this cholestatic liver disease in two forms – Intrahepatic and extrahepatic obstruction. In this article, we will discuss bilirubin, metabolism of bilirubin, normal range of bilirubin, and its clinical relevance. Further, we will also know the difference between conjugated and unconjugated bilirubin.

What is the Difference Between Conjugated and Unconjugated Bilirubin?

Sumit Sharma

Jaundice

Imran ALi

Red Blood Cell Destruction kau

guestbce519

Jaundice - Etiology, pathogenesis, Clinical features, Investigation, Treatmen...

Chetan Ganteppanavar

Heme catabolism.pptx

SubhashreeMahapatro

Similar to What is delta bilirubin? (20)

Bililrubin

Bilirubin metabolism

Bilirubin

Jaundice

Bilirubin estimation

Ictericia5

HEME DEGRADATION

Bilirubin 1

Bilirubin metabolism, Hemolytic anemia-classification and lab diagnosis.pptx

dr gurjinder bilirubin estimation.pptx

Liver function tests

Bilirubin metabolism

Bilirubin Metabolism Rajendra

LIVER FUNCTIONS TESTS -1-

What is the Difference Between Conjugated and Unconjugated Bilirubin?

Jaundice

Red Blood Cell Destruction kau

Jaundice - Etiology, pathogenesis, Clinical features, Investigation, Treatmen...

Heme catabolism.pptx

More from KETAN VAGHOLKAR

Meckel’s diverticulum in a hernia sac is designated as a Littre’s hernia. It is an uncommon type of hernia. The diagnosis is invariably made at the time of surgery. Resection anastomosis of the adjacent segment of the small bowel with the diverticulum is a contentious issue. A case of Littre’s hernia is reported. A case of Littre’s hernia in a 17-year-old boy is reported to highlight the diagnostic and therapeutic issues confronting the attending surgeon. A short segment resection anastomosis of the small bowel along with the Meckel’s diverticulum was done. A herniorrhaphy was done with no complications. The diagnostic challenges, the dilemma of selecting the best option for removing Meckel’s diverticulum, and the choice of hernia repair are discussed. Littre’s hernia is invariably diagnosed intraoperatively. A short segment resection anastomosis of the adjacent small bowel and Meckel’s diverticulum prevents complications arising due to the diverticulum. A herniorrhaphy for a young patient and the use of an absorbable mesh for other age groups is advisable.

LITTRE’S HERNIA: A SURGICAL DILEMMA

KETAN VAGHOLKAR

Post-traumatic wounds especially after run over accidents are difficult to manage. The vascularity and regenerative potential of the tissues is severely compromised. Surgical intervention is of limited value. A conservative approach with concomitant hyperbaric oxygen therapy (HBOT) serves as a great salvage in such cases. A case of post-traumatic forefoot gangrene in a 27-year-old laborer is presented to highlight and create an awareness of the potential benefit of HBOT in salvage of distal parts of the lower extremity where the blood supply is severely compromised.

Hyperbaric oxygen therapy a boon for complex post traumatic wounds

KETAN VAGHOLKAR

Deep vein thrombosis (DVT) usually affects the deep vein of the legs, though it may also occur in the veins of the arms, mesenteric and cerebral veins. Venous thromboembolism can cause sudden pulmonary embolism with instantaneous death. In patients who have developed deep vein thrombosis there is likelihood of recurrent thrombosis and post thrombotic syndrome. Deep venous thrombosis is preventable in majority of the cases. Understanding the etiopathogenesis, clinical presentation, evaluation and management is essential for both prevention and management thereby reducing the morbidity and mortality associated with the disease.

Deep Vein Thrombosis

KETAN VAGHOLKAR

Background: Fluid collection in a femoral hernia sac designated as a femorocele is an extremely uncommon surgical condition. Till date 9 cases of unilateral femorocele and one case of bilateral femorocele have been reported in English literature. Objective: Thus making the case presented the second case of bilateral femorocele in English literature. Case report: A case of bilateral femorocele in a patient suffering from rheumatic heat disease who had undergone dual valvular replacement with ascites due to cardiac cirrhosis is presented to highlight the surgical challenges in management of such a rare case. Discussion: Pathophysiology, clinical features, investigations and managemeny of femorocele are discussed. Conclusion: Contrast enhanced CT scan of the abdomen and scrotum is diagnostic. Open surgery in the form of dissection of sac with high ligation followed by obliteration of femoral ring is therapeutic. There is no scope of laparoscopy in such a case.

Bilateral Secondary Femorocele in a Case of Ascites Due to Cardiac Cirrhosis ...

KETAN VAGHOLKAR

Sliding inguinal hernia continues to be the most challenging hernia to treat. Both diagnosis and treatment pose a dilemma to the attending surgeon. Understanding the pathological anatomy of the sliding inguinal hernia is essential for optimal choice of surgical procedure without causing damage to the involved viscera. A case of sliding inguinal hernia is presented to highlight the diagnostic and technical challenges for repair of sliding hernia. Majority of sliding hernias are diagnosed at the time of surgery. Sigmoid colon is a commonest content in a left sided sliding hernia. Bevan’s technique is best suited to deal with the sac followed by Lichtenstein tension-free mesh repair.

Sliding hernia.pdf

KETAN VAGHOLKAR

Gallbladder carcinoma is fifth most common gastrointestinal malignancy. Main indication for cholecystectomy is gallstone disease. Majority of gallbladder carcinomas are diagnosed during the course of histopathological evaluation of specimens obtained at cholecystectomy. Accomplishing radical cholecystectomy is advisable in these patients. Technically difficult gallbladder dissection during the course of laparoscopic surgery should raise a high suspicion of malignancy. Specimen retrieval bags should be used in all cases to avoid external spillage of bile giving rise to port side metastasis. A good outcome depends on prompt diagnosis and radical surgical resection. It is essential for a general surgeon to be aware of predisposing factors, pathology, patterns of presentation, and surgical options in gallbladder carcinoma.

Carcinoma of the gall bladder.pdf

KETAN VAGHOLKAR

Fournier’s gangrene is a severe necrotizing fasciitis affecting the scrotum, perianal and perineal region. Development of this condition after inguinal hernia repair is extremely rare. A 54-year-old diabetic male patient who had undergone right inguinal hernia repair in a private clinic presented with severe necrotizing infection of the scrotum, predominantly of the right side. He was referred to our surgical unit. Initial resuscitation followed by broad spectrum antibiotic therapy and aggressive debridement of necrotic tissue followed by closure of scrotum was performed with excellent outcome. The purpose of presenting this case is to create awareness about this complication after hernia repair surgery especially in cases with comorbidities like diabetes mellitus.

Fournier’s gangrene of the scrotum after inguinal hernia repair: case report

KETAN VAGHOLKAR

Hydrocele of the Canal of Nuck (HCN) is a rare condition seen in adult females. Diagnosis of HCN poses a great challenge to the attending surgeon. There are various variants of embryological abnormality of the processes vaginalis manifesting in different forms. Understanding the embryological development of the processes vaginalis and the gubernaculum in female is therefore essential for determining the best surgical option for treating these rare cases.

Hydrocele of Canal of Nuck.pdf

KETAN VAGHOLKAR

Carbuncle is a confluent folliculitis that is infection affecting multiple hair follicles leading to multiple sinuses discharging pus. It is commonly seen on the back of immuno-compromised patients. Admission to hospital with aggressive treatment, both systemic and locally is necessary. Optimisation of co-morbidities such as diabetes, adequate hydration, and antibiotics and are mainstay of initial treatment. Surgical intervention in the form of debridement and desloughing followed by wound care is the next line of management. Patient education at the time of discharge is necessary for prevention of recurrence.

Carbuncle: A challenging infective lesion

KETAN VAGHOLKAR

Cases of self-inserted foreign bodies into the lower urinary tract are uncommon. They are associated with a mental illness called polyembolokoilomania. The site, size and nature of the foreign body determines both the symptomatology and complications. A case of self-inserted needle into the penile urethra by a 15-year-old boy is presented. A plain X-ray of the pelvis revealed the needle. The needle was successfully removed by cystoscopy. Plane X-ray imaging and CT scan are essential to locate the site, size, and nature of the foreign body. Endoscopic approach is preferred in majority cases. Psychiatric counselling in the post-operative period is required to prevent further episodes of reinsertion of such foreign bodies.

Foreign body in the male urethra: case report

KETAN VAGHOLKAR

Introduction: Morel-Lavalleé lesion is an uncommon closed degloving injury usually affecting the lower extremity. Although these lesions have been documented in literature, yet there is no standard treatment algorithm for the same. A case of Morel-Lavallée lesion following blunt injury to the thigh is therefore presented to highlight the diagnostic and therapeutic challenges in managing such lesions. The aim of presenting the case is to create awareness of clinical presentation, diagnosis, and management of Morel-Lavallée lesions, especially in the setting of polytrauma patients. Case Report: A case of Morel-Lavallée lesion in a 32-year-old male with history of a blunt injury to the right thigh caused by a partial run over accident is presented. A magnetic resonance imaging (MRI) was done to confirm the diagnosis. A limited open approach for evacuating the fluid in the lesion was performed followed by irrigation of the cavity with a combination of 3% hypertonic saline and hydrogen peroxide in order to induce fibrosis to obliterate the dead space. This was followed by continuous negative suction accompanied with a pressure bandage. Conclusion: A high index of suspicion is necessary especially in cases of severe blunt injuries to the extremities. MRI is essential for early diagnosis of Morel-Lavallée lesions. A limited open approach is a safe and effective option for treatment. The use of 3% hypertonic saline along with hydrogen peroxide irrigation of the cavity to induce sclerosis is a novel method for treating the condition.

Morel-Lavallée Lesion: Uncommon Injury often Missed

KETAN VAGHOLKAR

Background: The development of a pseudocyst after mesh repair of an incisional hernia is a rare complication. Both diagnosis and management pose a great challenge to the attending surgeon. Therefore, the need to report such an uncommon complication and its management in order to create awareness of this distinct though rare entity. Case report: A pseudocyst formation following an onlay mesh repair of an incisional hernia is reported. Contrast-enhanced CT scan was diagnostic. It revealed a well-formed cyst with no communication with the peritoneal cavity. Complete excision of the cyst was curative. Conclusion: Pseudocyst formation is a rare complication following mesh repair. Contrast-enhanced CT scan is essential for confirming the diagnosis. Complete surgical resection of the cyst is the mainstay of surgical treatment.

ABDOMINAL WALL PSEUDOCYST COMPLICATING INCISIONAL HERNIA REPAIR

KETAN VAGHOLKAR

Background: Traumatic lumbar hernia is due to shearing of bony insertions of the muscle in the lumbar region. In recurrent cases, there is more attenuation of muscles. This makes fixation of the mesh extremely difficult. Hence, the need to develop a new technique. Case report: A 27-year-old male presented with a recurrent post-traumatic right- sided lumbar hernia. He had a severe two wheeler accident. Following the accident he had undergone various surgical interventions for a fractured pelvis with a deglowing injury involving the right gluteal region and upper thigh. He had also developed a post-traumatic lumbar hernia for which he had undergone open mesh repair. Subsequently he developed recurrence of the post traumatic right-sided lumbar hernia. After complete investigation he underwent open mesh repair for the recurrent post traumatic lumbar hernia. The defect was wide and was devoid of healthy surrounding muscles. The mesh was fixed to the ileal bone with bone anchors and to the twelfth rib with trans-osseous fiber sutures passed through holes drilled in the twelfth rib. Flaps were created from the remnant surrounding attenuated muscles. They were double-breasted to cover the mesh. Postoperative outcome was excellent with no recurrence for the last six months. Discussion: The various anatomical and technical considerations of bone fixation of the mesh for hernia repair are discussed. Conclusion: Bone fixation of the mesh with bone anchors is a viable option especially in cases where there is severe attenuation of adjacent muscles for mesh fixation.

Novel Technique for Mesh Fixation to the Bone in Recurrent Post Traumatic Lum...

KETAN VAGHOLKAR

Background: Acute calculous cholecystitis is one of the commonest biliary tract emergencies. The advent of laparoscopic cholecystectomy has changed the treatment approach from conservative to emergency surgical intervention. As a result, emergency laparoscopic cholecystectomy is emerging as the standard of care. Therefore, the needs to evaluate the various factors that determine the procedure’s safety. Aims: The study aims to evaluate the efficacy and safety of laparoscopic cholecystectomy in acute calculous cholecystitis. Materials and methods: Consecutive patients who underwent laparoscopic cholecystectomy for acute calculous cholecystitis over a 2-year-old period were studied prospectively. Results: 75 patients were evaluated. The mean age was 49.48 years. Majority presented with right hypochondriac pain. 22 patients had hypertension. 26 had diabetes and 6 patients had both hypertension and diabetes. In 61 patients the mean duration of surgery was less than 60 minutes. 5 patients needed conversion to an open procedure. 10 patients developed complications. Mean hospital stay was 4.34 days. Conclusion: Early emergency laparoscopic cholecystectomy is a safe and viable option for treating acute calculous cholecystitis

LAPAROSCOPIC CHOLECYSTECTOMY IN ACUTE CALCULOUS CHOLECYSTITIS (STUDY OF 75 CA...

KETAN VAGHOLKAR

Lipoma is one of the most common soft tissue tumor arising from the mesenchyme. It is slow growing, encapsulated, and usually benign in nature. Tumors over the back, shoulder, and neck region have a high propensity to assume large size thereby getting redefined as a giant lipoma when they exceed 10 cm in width or weigh more than 1000 grams. MRI is the investigation of choice for evaluating giant lipomas. Fine needle aspiration cytology (FNAC) or frozen section may be pertinent in suspected cases of liposarcoma. Complete surgical incision is the treatment of choice. A case of a giant lipoma on the back of a 64-year-old lady is presented with a view to revisit conceptual understanding of the clinical evaluation, investigation, and management of giant lipomas.

Giant lipoma over the back

KETAN VAGHOLKAR

Background: Appendicectomy is one of the common procedures performed by a general surgeon. However, the advent of laparoscopic appendicectomy has reduced the number of open appendicectomies performed. Therefore there is a need to study the advantages of the laparoscopic approach over the traditional open approach. Aims: The study aimed to compare laparoscopic appendicectomy with open appendicectomy based on various intraoperative and postoperative parameters Materials and methods: 50 patients undergoing interval appendicectomy were randomised into two groups. Group A comprised 25 patients who underwent laparoscopic appendicectomy and group B comprised 25 patients who underwent open appendicectomy. Results: Confirmation of diagnosis and evaluation of intraoperative findings was easier in group A patients. In addition, early commencement of feeds with early bowel movements, reduced need for postoperative analgesia due to less pain, lesser complications and shorter duration of hospital stay was observed in group A patients. Conclusion: Laparoscopic appendicectomy has better outcomes rendering it a preferable procedure for appendicectomy.

LAPAROSCOPIC VERSUS OPEN APPENDICECTOMY IN ADULTS. (STUDY OF 50 CASES)

KETAN VAGHOLKAR

Background: The incidence of abdominal tuberculosis is increasing. Preoperative diagnosis continues to be the biggest challenge. Diagnosis is established only after histopathological examination. The modes of presentation and therapeutic options need to be assessed. Objectives: To study the patterns of presentations, the extent of organ involvement and therapeutic options. Materials and methods: Fifty histopathologically proven cases of abdominal tuberculosis were studied. In addition, epidemiologic data, clinical patterns of presentation, diagnostic and various surgical options, including outcomes, were studied. Results: The mortality in the study was 8%. The disease was commonly seen in 21 to 40 years old and commonly seen in females. HIV positivity, anaemia and hypoproteinaemia were associated with poor outcomes. Four types of presentations were observed. Diagnostic laparoscopy enabled early histopathological diagnosis of biopsy specimens. Chemotherapy is the mainstay of treatment Surgery is a significant adjunct in diagnosing and managing complications. Patients presenting with perforative peritonitis had a poor prognosis Conclusion: Critical evaluation of chronic abdominal pain is essential. Supportive evidence such as the history of TB or contact with a patient suffering from TB is highly suggestive of abdominal tuberculosis. Radiological tests are highly suggestive but not diagnostic. Diagnostic laparoscopy enables tissue diagnosis. Chemotherapy accompanied by surgical intervention for complications is the mainstay of treatment.

ABDOMINAL TUBERCULOSIS (STUDY OF 50 CASES)

KETAN VAGHOLKAR

Background: Perforative peritonitis poses a significant diagnostic and therapeutic challenge to the attending surgeon. Delay in diagnosis followed by sub-optimal treatment may lead to many complications, thereby increasing both morbidity and mortality. This is by virtue of various factors which affect the prognosis. Hence the need arises to identify these prognostic factors. Aims and Objectives: To study the various etiological factors of perforative peritonitis and to identify prognostic factors and comorbid conditions which influence the outcome in perforative peritonitis. Materials and Methods: 50 patients with an established diagnosis of perforative peritonitis due to various aetiologies confirmed by clinical and radiological investigations were included in the study and studied prospectively. On admission to the hospital, various haematological and radiological investigations were conducted to confirm the diagnosis. Patients subsequently underwent surgical intervention. Postoperative recovery and outcomes assessed. Results were tabulated and statistically analysed. Results: The mean age of patients in the study was 36.5 ±5 years. Patients who presented in an advanced stage developed complications. The majority of patients were males. The interval between the onset of symptoms and operative intervention was directly related to postoperative complications. Pneumoperitoneum was the most common x-ray finding, followed by dilated bowel loops with free fluid in the peritoneal cavity as the most common ultrasonography finding. Tachycardia and oliguria, which were markers of the severity of the disease process, were associated with an increased rate of complications. Peptic ulcer perforation was the most common, followed by perforations caused by infective aetiology. Perforations caused by infective aetiology had a higher rate of complication. Primary closure of the perforation was the most commonly performed procedure. Significant abdominal contamination found intraoperatively contributed to a negative outcome, as were comorbid conditions, which also increased the complication rate significantly. Conclusion: Delayed intervention after the onset of symptoms, tachycardia, oliguria and comorbidities are associated with a higher complication rate. Radiological investigations help in confirming the diagnosis. Infective aetiology of the perforation and extensive peritoneal contamination was associated with higher complication rates. Prompt and aggressive resuscitation on admission, optimum antibiotic administration, and early meticulous surgical intervention can reduce morbidity and mortality to a bare minimum.

PERFORATIVE PERITONITIS: CONTINUING SURGICAL CHALLENGE.(PROSPECTIVE STUDY OF ...

KETAN VAGHOLKAR

Background: Skin approximation is a very important step in a surgical operation. The quality of skin approximation affects the quality of the scar. Traditional skin suturing is associated with quite a few wound complications. Staple approximation is an innovative alternative with good results. Aim: The aim of the study is to compare traditional suturing of skin edges versus staple approximation and to evaluate the impact of these techniques on wound complications such as pain, surgical site infections, scarring and patient satisfaction. Materials and methods: 150 patients are included in the study and divided into two groups. Group A (skin suturing) and group B (staple approximation). The effect of the technique on wound healing is evaluated. Results: Patients belonging to group B (staple approximation) had less pain, shorter skin closure duration, no wound complications, fine scarring and greater patient satisfaction. Conclusion: Staple approximation of skin edges during the closure of laparotomy incisions is recommended.

COMPARISON BETWEEN SUTURING AND STAPLE APPROXIMATION OF SKIN IN ABDOMINAL INC...

KETAN VAGHOLKAR

Background: Laparoscopic cholecystectomy is a new alternative to the traditional open approach for treating calculous cholecystitis. It is, therefore, necessary to assess the efficacy of laparoscopic cholecystectomy over the open cholecystectomy. Objectives: To compare the surgical outcomes of laparoscopic cholecystectomy with those of open cholecystectomy. Materials and methods: 50 patients diagnosed as symptomatic cholelithiasis proven by radiological investigations were distributed into two groups of 25 each. Group A patients were subjected to laparoscopic cholecystectomy, and group B patients underwent open cholecystectomy. The surgical outcomes were studied prospectively. Intraoperative complications and postoperative care parameters were evaluated. Results: Mean age of patients in group A was 46.68±13.6 years, and in the group, B was 42.64±14.1 years. Majority of patients were in the age group of 41 to 60 years. Patients who had diabetes in group B developed wound infections, whereas diabetic patients in group A did not develop any infection. Significant bleeding necessitating blood transfusion occurred in one patient belonging to group B. The duration of postoperative analgesia required was 3.16 days in group A and 5.16 days in group B. The duration of postoperative antibiotics administered in laparoscopic and open cases was 1.48 and 4.8 days, respectively. One of the patients in group A developed a postoperative biliary leak, whereas none in group B had any such complication. The commencement of oral feeds and after that return of bowel movements was earlier in group A than group B. The mean hospital stay was 4.5 days in group A as compared to 6.3 days in group B. Conclusion: Laparoscopic cholecystectomy is superior to open cholecystectomy regarding reduced postoperative discomfort and pain, antibiotic and analgesic requirement, early commencement of oral feeds, and shorter duration of hospitalization

COMPARATIVE STUDY BETWEEN LAPAROSCOPIC AND OPEN CHOLECYSTECTOMY (STUDY OF 50 ...

KETAN VAGHOLKAR

More from KETAN VAGHOLKAR (20)

LITTRE’S HERNIA: A SURGICAL DILEMMA

Hyperbaric oxygen therapy a boon for complex post traumatic wounds

Deep Vein Thrombosis

Bilateral Secondary Femorocele in a Case of Ascites Due to Cardiac Cirrhosis ...

Sliding hernia.pdf

Carcinoma of the gall bladder.pdf

Fournier’s gangrene of the scrotum after inguinal hernia repair: case report

Hydrocele of Canal of Nuck.pdf

Carbuncle: A challenging infective lesion

Foreign body in the male urethra: case report

Morel-Lavallée Lesion: Uncommon Injury often Missed

ABDOMINAL WALL PSEUDOCYST COMPLICATING INCISIONAL HERNIA REPAIR

Novel Technique for Mesh Fixation to the Bone in Recurrent Post Traumatic Lum...

LAPAROSCOPIC CHOLECYSTECTOMY IN ACUTE CALCULOUS CHOLECYSTITIS (STUDY OF 75 CA...

Giant lipoma over the back

LAPAROSCOPIC VERSUS OPEN APPENDICECTOMY IN ADULTS. (STUDY OF 50 CASES)

ABDOMINAL TUBERCULOSIS (STUDY OF 50 CASES)

PERFORATIVE PERITONITIS: CONTINUING SURGICAL CHALLENGE.(PROSPECTIVE STUDY OF ...

COMPARISON BETWEEN SUTURING AND STAPLE APPROXIMATION OF SKIN IN ABDOMINAL INC...

COMPARATIVE STUDY BETWEEN LAPAROSCOPIC AND OPEN CHOLECYSTECTOMY (STUDY OF 50 ...

Recently uploaded

💚Chandigarh Call Girls 💯Riya 📲🔝8868886958🔝Call Girls In Chandigarh No💰Advance Cash On Delivery Service Chandigarh Call Girls Service punjab ❤️🍑 📲Lucky 8868886958📲 💚👄🫦 Independent Escort Service Chandigarh Call Now :- 8868886958 Lucky Call Girl In Chandigarh | Chandigarh Call Girl | Call girl service in Chandigarh | Call Girls In Chandigarh | Chandigarh Call Girls Their services range from erotic encounters and movie dates to in-call and out-call services, making this option available 24/7. Available for services including NSA, threesomes and foursomes sessions as well as massage services and casual foreplay - they even provide real girlfriend experience. Find one online or visit local women's clubs, hotels or restaurants. Hiring a Chandigarh call girl for an evening or day out can be the perfect addition to your social gathering or office event, or you could arrange for her to visit your home or hotel room. Not only are these women gorgeous, they're intelligent as well, with great senses of humor - sure to please and leave you wanting more. If you want a cheap escort in Chandigarh, look for someone who is either a student or works part time so that she will always be available when you need her. In addition to this, look for housewives as this ensures they have stable lives that can keep you satisfied for extended periods. These beautiful ladies will capture your attention at first sight with stunning eyes and full, seductive lips; not to mention a seductive personality that makes you want to spend more time with them; moreover they are discreet enough to meet up anywhere nearby! Hiring a call girl in Chandigarh can be done through either the internet or calling her directly, with services like massage or sex sessions offered to request from specific agencies within a few hours of making contact. Furthermore, text the girl directly for price quotes!

💚Chandigarh Call Girls 💯Riya 📲🔝8868886958🔝Call Girls In Chandigarh No💰Advance...

Sheetaleventcompany

❤️Chandigarh Escorts Service☎️9814379184☎️ Call Girl service in Chandigarh☎️ Chandigarh Call Girls Service ☎️ Call Girls In Chandigarh BEST Call Girls in CHANDIGARH Escort Service provide Cute Nice sweet and Sexy Models in beautiful CHANDIGARH city cash in hand to hand call girl in CHANDIGARH and CHANDIGARH escorts. HOT & SEXY MODELS // COLLEGE GIRLS IN CHANDIGARH AVAILABLE FOR COMPLETE ENJOYMENT WITH HIGH PROFILE INDIAN MODEL AVAILABLE HOTEL & HOME ★ SAFE AND SECURE HIGH CLASS SERVICE AFFORDABLE RATE ★ 100% SATISFACTION,UNLIMITED ENJOYMENT. ★ All Meetings are confidential and no information is provided to any one at any cost. ★ EXCLUSIVE Profiles Are Safe and Consensual with Most Limits Respected ★ Service Available In: - HOME & 24x7 :: 3 * 5 *7 *Star Hotel Service .In Call & Out call Services : ★ A-Level (5 star escort) ★ Strip-tease ★ BBBJ (Bareback Blowjob)Receive advanced sexual techniques in different mode make their life more pleasurable. ★ Spending time in hotel rooms ★ BJ (Blowjob Without a Condom) ★ Completion (Oral to completion) ★ Covered (Covered blowjob Without a Condom)Chandigarh Call Girls

❤️Chandigarh Escorts Service☎️9814379184☎️ Call Girl service in Chandigarh☎️ ...

Sheetaleventcompany

Whitefield { Call Girl in Bangalore ₹7.5k Pick Up & Drop With Cash Payment 6378878445 Call Girls VIP Call Girl Bangalore As Enjoy Never Ending Bangalore VIP Call Girls is highly qualified professionals. #S10 They will offer only top quality services and never try to scam or drain you of money; in fact, they strive to give complete satisfaction so that each cent spent was worth its worth. Furthermore, these professionals pride themselves in keeping customer details confidential; any information gleaned will never be shared with any third party. Two shots with one girl: ₹4500/in-call, ₹7500/out-call Body to body massage with : ₹5500/in-call Full night for one person: ₹7000/in-call, ₹12000/out-call •𝐂𝐨𝐥𝐥𝐞𝐠𝐞 𝐆𝐢𝐫𝐥𝐬 •𝐇𝐨𝐮𝐬𝐞𝐰𝐢𝐯𝐞𝐬 •𝐇𝐢𝐠𝐡 𝐏𝐫𝐨𝐟𝐢𝐥𝐞 𝐆𝐢𝐫𝐥𝐬 •𝐑𝐚𝐦𝐩 𝐌𝐨𝐝𝐞𝐥𝐬 •𝐅𝐨𝐫𝐞𝐢𝐠𝐧𝐞𝐫 𝐆𝐢𝐫𝐥𝐬 𝐎𝐮𝐫 𝐞𝐬𝐜𝐨𝐫𝐭 𝐬𝐞𝐫𝐯𝐢𝐜𝐞𝐬 •𝐇𝐉 (𝐇𝐚𝐧𝐝 𝐉𝐨𝐛) •𝐁𝐉 (𝐁𝐥𝐨𝐰𝐣𝐨𝐛) # Completion # (Oral To Completion) # Special Massage # O-Level (Oral ) # Oral With A Noncondom) # COB (Come On Body) # Extraball (Have Many Times) # All Meetings 100%Safe 𝐭𝐡𝐞 𝐝𝐮𝐫𝐚𝐭𝐢𝐨𝐧 𝐨𝐟𝐟𝐞𝐫𝐞𝐝 𝐦𝐚𝐲 𝐞𝐱𝐭𝐞𝐧𝐭 15 𝐦𝐢𝐧𝐮𝐭𝐞𝐬 𝐚𝐜𝐜𝐨𝐫𝐝𝐢𝐧𝐠 𝐭𝐨 𝐲𝐨𝐮𝐫 𝐧𝐞𝐞𝐝 𝐰𝐡𝐞𝐫𝐞 𝐲𝐨𝐮 𝐰𝐢𝐥𝐥 𝐧𝐨𝐭 𝐛𝐞 𝐜𝐡𝐚𝐫𝐠𝐞𝐝 𝐟𝐨𝐫 𝐭𝐡𝐚𝐭 𝐝𝐮𝐫𝐚𝐭𝐢𝐨𝐧 . ✓𝐢𝐟 𝐲𝐨𝐮 𝐰𝐚𝐧𝐭 𝐭𝐨 𝐬𝐩𝐞𝐧𝐝 𝐬𝐨𝐦𝐞 𝐦𝐨𝐫𝐞 𝐭𝐢𝐦𝐞 𝐭𝐡𝐞𝐧 𝐲𝐨𝐮 𝐰𝐢𝐥𝐥 𝐛𝐞 𝐜𝐡𝐚𝐫𝐠𝐞𝐝 𝐞𝐱𝐭𝐫𝐚 𝐚𝐦𝐨𝐮𝐧𝐭 𝐰𝐡𝐢𝐜𝐡 𝐲𝐨𝐮 𝐡𝐚𝐯𝐞 𝐭𝐨 𝐩𝐚𝐲 𝐚𝐭 𝐭𝐡𝐞 𝐬𝐚𝐦𝐞 𝐭𝐢𝐦𝐞 . ✓𝐞𝐯𝐞𝐫𝐲 𝐭𝐡𝐢𝐧𝐤 𝐢𝐬 𝐚𝐥𝐥𝐨𝐰𝐞𝐝 𝐞𝐱𝐜𝐞𝐩𝐭 𝐚𝐧𝐚𝐥 𝐚𝐧𝐝 𝐬𝐞𝐫𝐯𝐢𝐜𝐞 𝐰𝐢𝐭𝐡𝐨𝐮𝐭 𝐩𝐫𝐨𝐭𝐞𝐜𝐭𝐢𝐨𝐧 . ✨✨𝐚𝐯𝐚𝐢𝐥𝐚𝐛𝐢𝐥𝐢𝐭𝐲 ✨✨ ✨✨𝐭𝐡𝐚𝐧𝐤𝐬 𝐲𝐨𝐮 ✨✨ 𝐒𝐚𝐭𝐢𝐬𝐟𝐲 𝐚𝐥𝐥 𝐲𝐨𝐮𝐫 𝐬𝐞𝐱𝐮𝐚𝐥 𝐜𝐫𝐚𝐯𝐢𝐧𝐠𝐬 100% 𝐩𝐫𝐞𝐦𝐢𝐮𝐦 𝐬𝐞𝐫𝐯𝐢𝐜𝐞 𝐆𝐢𝐫𝐥𝐬 𝐝𝐢𝐫𝐞𝐜𝐭𝐥𝐲 𝐭𝐨 𝐲𝐨𝐮𝐫 𝐥𝐨𝐜𝐚𝐭𝐢𝐨𝐧 𝐆𝐞𝐧𝐮𝐢𝐧𝐞 𝐚𝐧𝐝 𝐕𝐈𝐏 𝐦𝐨𝐝𝐞𝐥𝐬 𝐃𝐚𝐢𝐥𝐲 𝐮𝐩𝐝𝐚𝐭𝐞 𝐨𝐧 𝐧𝐞𝐰 𝐮𝐩𝐜𝐨𝐦𝐢𝐧𝐠 𝐦𝐨𝐝𝐞𝐥𝐬 𝐆𝐞𝐭 15% 𝐝𝐢𝐬𝐜𝐨𝐮𝐧𝐭 𝐨𝐧 𝐧𝐞𝐰𝐥𝐲 𝐚𝐫𝐫𝐢𝐯𝐞𝐝 𝐦𝐨𝐝𝐞𝐥𝐬 Call fast 👙👙💋 welcome guys 💋💋📞 6378878445

Whitefield { Call Girl in Bangalore ₹7.5k Pick Up & Drop With Cash Payment 63...

dishamehta3332

Goa Call Girl Service 📞9xx000xx09📞Just Call Divya📲 Call Girl In Goa No💰Advance Cash On Delivery Service. Call Girl Service In Goa 📞9xx000xx09📞Just Call Divya📲 Call Girl In Goa No💰Advance Cash On Delivery Service Call Girl Near Me Booking Details Are here: just visit website: https://hotbabe24.com #Call Girl In Goa, #Goacallgirls #CallgirlserviceGoa, #CallgirlsinGoa Website on rent : mailto:indiancallgirl4rent@gmail.com "Call Girls Goa VIP Call Girls Service Goa.. Booking Open Now We Are Providing Safe & Secure High Class girl women sucking men Services Affordable Rate 100% Satisfaction, Unlimited Enjoyment. Any Time for Model/ women seeking men in royal call girl High class luxury and premium call girl agency. ✔️High class luxury and premium escorts agency We Provide Well Educated, Royal Class Female, High-class Escorts agency offering a top high class escort service in the royal Escorts ✔️ Get High Profile queens , Well Educated , Good Looking , Full Cooperative Model Services. you can see me at my comfortable Hotels or I can visit you in hotel Our Service Available IN All Services 3/5/7 Star Hotels, In call /Out call Service 24/7.. ✔️ All Meetings We Provide Hottest Female With Me Are Safe And Consensual With Most Limits Respected Complete Satisfaction Guaranteed...Service Available In:- 24/7 3 * 5 *7 *Star Hotel Service In. In Call Out call service Avilable also. ✔️ I guarantee you to have an unforgettable experience with me A curvy body, long hair and silky smooth skin. She is an independent royal Escorts/Women Seeking Men model will give you more pleasure & Full satisfaction. ✔️ I am very sensual and flirtatious with charming personality! I love to laugh and my bright smile is ever Present. ,Hotel & Home Services CALL PLZZ ✔️Available Near All 3* 4* 5* 7* Hotels Of I Want Only Hotel Name , Guest Name , Room No. Only For Confirmation.✔️ Nandani... agency...⭐⭐⭐⭐⭐ VIP...Service ✣ ✤ ✥ ✦ TIME WASTERS AND BARGAINERS ARE PLEASE EXCUSE, WE RESPECT YOUR SAFETY AND PRIVACY AND EXPECT TH WHATSAPP: 9xx000xx09 CALL ME" 9xx000xx09

Goa Call Girl Service 📞9xx000xx09📞Just Call Divya📲 Call Girl In Goa No💰Advanc...

Sheetaleventcompany

Dehradun Call Girl Service ❤️🍑 8854095900 👄🫦Independent Escort Service Dehradun WhatsApp Chat: ☎️ +91-8854095900 Call Girls Dehradun offer you everything from intimate moments to wild nights - be it intimate or wild. Their girls are always prepared to meet all your needs and desires so you're assured a memorable experience with them. Beautiful Babes are sure to turn heads wherever they go, captivating men with their seductive personalities and captivating looks - not to mention their sensually alluring bodies that are sure to satisfy all your naughty fantasies, from blowjobs to anal massages; not forgetting BDSM and orgies as well. Show them some appreciation when the time is right. Call Girl Dehradun that their clients can be very demanding. To maintain their reputation and gain more clients, these sexy call girls always work tirelessly to provide exceptional service that ensures each customer's happiness - so much so that many men seek them out to have an unforgettable experience with Passionate about providing erotic pleasure for their clients - fulfilling all sexy fantasies while offering role play services such as BDSM. ★OUR BEST SERVICES: - FOR BOOKING ★ A-Level (5-star escort) ★ Strip-tease ★ BBBJ (Bareback Blowjob) ★ Spending time in my rooms ★ BJ (Blowjob Without a Condom) ★. Extra ball (Have ride many times) ☛ ☛ ☛ ✔✔ secure✔✔ 100% safe WHATSAPP CALL ME💥✨✨⭐⭐⚡💦💦💨🔥💫💫 Their services range from erotic encounters and movie dates to in-call and out-call services, making this option available 24/7. Available for services including NSA, threesomes and foursomes sessions as well as massage services and casual foreplay - they even provide real girlfriend experience. Find one online or visit local women's clubs, hotels or restaurants. Hiring a Dehradun call girl for an evening or day out can be the perfect addition to your social gathering or office event, or you could arrange for her to visit your home or hotel room. Not only are these women gorgeous, they're intelligent as well, with great senses of humor - sure to please and leave you wanting more. If you want a cheap escort in Dehradun, look for someone who is either a student or works part time so that she will always be available when you need her. In addition to this, look for housewives as this ensures they have stable lives that can keep you satisfied for extended periods. These beautiful ladies will capture your attention at first sight with stunning eyes and full, seductive lips; not to mention a seductive personality that makes you want to spend more time with them; moreover they are discreet enough to meet up anywhere nearby! Hiring a call girl in Dehradun can be done through either the internet or calling her directly, with services like massage or sex sessions offered to request from specific agencies within a few hours of making contact. Furthermore, text the girl directly for price quotes!

Dehradun Call Girl Service ❤️🍑 8854095900 👄🫦Independent Escort Service Dehradun

Sheetaleventcompany

Call Girls Mussoorie Just Call 8854095900 Top Class Call Girl Service Available WhatsApp Chat : +91-8854095900 Get More Information About Mussoorie Escorts Service Mussoorie Escorts offer their services to their clients at any time of day or night - including sex, travel and tours. Contact them via telephone or the internet. Hire an escort as your movie partner, date or party companion - they're sure to exceed all your expectations. Girls available 24/7 make for great companions who offer sensual body massages and drinks/food service during your time together. Find one who fits with your personality or budget - these girls have you covered.

Call Girls Mussoorie Just Call 8854095900 Top Class Call Girl Service Available

Janvi Singh

Genuine Call Girls Hyderabad 9630942363 Book High Profile Call Girl in Hydera...

GENUINE ESCORT AGENCY

💚Call Girls In Amritsar 💯Anvi 📲🔝8725944379🔝Amritsar Call Girl No💰Advance Cash On Delivery Service Amritsar Call Girls Service punjab ❤️🍑 📲Anvi 8725944379📲 💚👄🫦 Independent Escort Service Amritsar Call Now :- 8725944379 Lucky Call Girl In Amritsar | Amritsar Call Girl | Call girl service in Amritsar | Call Girls In Amritsar | Amritsar Call Girls Their services range from erotic encounters and movie dates to in-call and out-call services, making this option available 24/7. Available for services including NSA, threesomes and foursomes sessions as well as massage services and casual foreplay - they even provide real girlfriend experience. Find one online or visit local women's clubs, hotels or restaurants. Hiring a Amritsar call girl for an evening or day out can be the perfect addition to your social gathering or office event, or you could arrange for her to visit your home or hotel room. Not only are these women gorgeous, they're intelligent as well, with great senses of humor - sure to please and leave you wanting more. If you want a cheap escort in Amritsar, look for someone who is either a student or works part time so that she will always be available when you need her. In addition to this, look for housewives as this ensures they have stable lives that can keep you satisfied for extended periods. These beautiful ladies will capture your attention at first sight with stunning eyes and full, seductive lips; not to mention a seductive personality that makes you want to spend more time with them; moreover they are discreet enough to meet up anywhere nearby! Hiring a call girl in Amritsar can be done through either the internet or calling her directly, with services like massage or sex sessions offered to request from specific agencies within a few hours of making contact. Furthermore, text the girl directly for price quotes!

💚Call Girls In Amritsar 💯Anvi 📲🔝8725944379🔝Amritsar Call Girl No💰Advance Cash...

Sheetaleventcompany

ANATOMY AND PHYSIOLOGY OF RESPIRATORY SYSTEM.pptx

Swetaba Besh

Call Girl Service In Jaipur 📞9xx000xx09📞Just Call Divya📲 Call Girl In Jaipur No💰Advance Cash On Delivery Service Call Girl Near Me Booking Details Are here: just visit website: https://hotbabe24.com #Call Girl In Jaipur, #Jaipurcallgirls #CallgirlserviceJaipur, #CallgirlsinJaipur Website on rent : mailto:indiancallgirl4rent@gmail.com "Call Girls Jaipur VIP Call Girls Service Jaipur.. Booking Open Now We Are Providing Safe & Secure High Class girl women sucking men Services Affordable Rate 100% Satisfaction, Unlimited Enjoyment. Any Time for Model/ women seeking men in royal call girl High class luxury and premium call girl agency. ✔️High class luxury and premium escorts agency We Provide Well Educated, Royal Class Female, High-class Escorts agency offering a top high class escort service in the royal Escorts ✔️ Get High Profile queens , Well Educated , Good Looking , Full Cooperative Model Services. you can see me at my comfortable Hotels or I can visit you in hotel Our Service Available IN All Services 3/5/7 Star Hotels, In call /Out call Service 24/7.. ✔️ All Meetings We Provide Hottest Female With Me Are Safe And Consensual With Most Limits Respected Complete Satisfaction Guaranteed...Service Available In:- 24/7 3 * 5 *7 *Star Hotel Service In. In Call Out call service Avilable also. ✔️ I guarantee you to have an unforgettable experience with me A curvy body, long hair and silky smooth skin. She is an independent royal Escorts/Women Seeking Men model will give you more pleasure & Full satisfaction. ✔️ I am very sensual and flirtatious with charming personality! I love to laugh and my bright smile is ever Present. ,Hotel & Home Services CALL PLZZ ✔️Available Near All 3* 4* 5* 7* Hotels Of I Want Only Hotel Name , Guest Name , Room No. Only For Confirmation.✔️ Nandani... agency...⭐⭐⭐⭐⭐ VIP...Service ✣ ✤ ✥ ✦ TIME WASTERS AND BARGAINERS ARE PLEASE EXCUSE, WE RESPECT YOUR SAFETY AND PRIVACY AND EXPECT TH WHATSAPP: 9xx000xx09 CALL ME" 9xx000xx09

Jaipur Call Girl Service 📞9xx000xx09📞Just Call Divya📲 Call Girl In Jaipur No💰...

Sheetaleventcompany

❤️Chandigarh Escorts Service☎️9809698092☎️ Call Girl service in Chandigarh☎️ Chandigarh Call Girls Service ☎️ Call Girls In Chandigarh BEST Call Girls in CHANDIGARH Escort Service provide Cute Nice sweet and Sexy Models in beautiful CHANDIGARH city cash in hand to hand call girl in CHANDIGARH and CHANDIGARH escorts. HOT & SEXY MODELS // COLLEGE GIRLS IN CHANDIGARH AVAILABLE FOR COMPLETE ENJOYMENT WITH HIGH PROFILE INDIAN MODEL AVAILABLE HOTEL & HOME ★ SAFE AND SECURE HIGH CLASS SERVICE AFFORDABLE RATE ★ 100% SATISFACTION,UNLIMITED ENJOYMENT. ★ All Meetings are confidential and no information is provided to any one at any cost. ★ EXCLUSIVE Profiles Are Safe and Consensual with Most Limits Respected ★ Service Available In: - HOME & 24x7 :: 3 * 5 *7 *Star Hotel Service .In Call & Out call Services : ★ A-Level (5 star escort) ★ Strip-tease ★ BBBJ (Bareback Blowjob)Receive advanced sexual techniques in different mode make their life more pleasurable. ★ Spending time in hotel rooms ★ BJ (Blowjob Without a Condom) ★ Completion (Oral to completion) ★ Covered (Covered blowjob Without a Condom)Chandigarh Call Girls

Chandigarh Call Girls Service ❤️🍑 9809698092 👄🫦Independent Escort Service Cha...

Sheetaleventcompany

💰Call Girl In Bangalore☎️63788-78445💰 Call Girl service in Bangalore☎️Bangalore Call Girls Service 💰 Call Girls In Bangalore Call Mrs Naina Ji +91-6378878445 We offer all types of girls of your choice with space. Our escorts are fully cooperative and understand your needs. All types of call girls like Housewives, College girls,#J11 Russian girls, Muslim girls, Afghani girls, Bengali girls, Working girls, south Indian girls, Punjabi girls, etc. In-Call: — You Can Reach At Our Place in bangalore Our place Which Is Very Clean Hygienic 100% safe Accommodation. Out-Call: — Service for Out Call You have To Come Pick The Girl From My Place We Also Provide Door-Step Services Hygienic: — Full Ac Neat And Clean Rooms Available In Hotel 24 * 7 Hrs In bangalore Our Services and Rates: – One Shot — 2500/in call (time ½ hour), 5000/out call Two shot with one girl — 5000/in call (time 1 hour), 6000/out call Body to body massage with sex- 3000/in call (time 1 hour) full night for one person– 8000/in call, 10000/out call (shot limit 4 shot) We are available 24*7 all days of the year Call us — 6378878445 !! Thank you for Visiting.

💰Call Girl In Bangalore☎️63788-78445💰 Call Girl service in Bangalore☎️Bangalo...

gragneelam30

Premium Call Girls Nagpur {9xx000xx09} ❤️VVIP POOJA Call Girls in Nagpur Maharashtra. Exclusive Nagpur Escorts 👉 Just Call Us: 9xx000xx09 VIP Call Girls Nagpur 100% Genuine at your Door Step Available 24x7 Booking Details Are here: just visit website: https://www.callgirlescortservice.com/nagpur-call-girls.html #Call Girl In Nagpur, #Nagpurcallgirls #CallgirlserviceNagpur, #CallgirlsinNagpur Website on rent : mailto:indiancallgirl4rent@gmail.com 09-May-2024( Mj) Click On WhatsApp Chat +91-9xx000xx09 Escort Service In Nagpur Nagpur Escorts Make You Feel Like Royalty Nagpur Escorts catering to high profile clients are available 24-7 to meet their clients' needs and are also available for dinner dates, business conferences, foreign travel trips and clubbing activities. Their customers are contacted directly through in order to prevent risky situations from developing.is home to some of Maharashtra's most beautiful women. These girls come highly educated with great backgrounds; furthermore they are extremely beautiful and will make you feel like royalty if hired for hours or days! Siya Khan | FOR BOOKING CALL Our All Services :- 1 )★ (Oral to consummation) bjnonCovered 2 )★ Special Massage 3 )★ O-Level (Oral sex) 4 )★ Blow Job; 5 )★ COB (Come On Body) 6 )★. Extraball (Have sex ordinarily) 7 )★ A-Level (5 star escort) 8 )★ Strip-bother 9 )★ BBBJ (Bareback Blowjob) 10 )★ Spending time in my rooms 11 )★ BJ (Blowjob Without a Condom) 12 )★ COF (Come On Face) 13 )★ Completion

Premium Call Girls Nagpur {9xx000xx09} ❤️VVIP POOJA Call Girls in Nagpur Maha...

Sheetaleventcompany

Ahmedabad Call Girls Book Now 9630942363 Top Class Ahmedabad Escort Service A...

GENUINE ESCORT AGENCY

Intramuscular & Intravenous Injection.pptx

saranpratha12

Race Course Road } Book Call Girls in Bangalore | Whatsapp No 6378878445 VIP Escorts Service Available 24*7 Book Call Mrs Janvi Ji +91-6378878445 We offer all types of girls of your choice with space. Our escorts are fully cooperative and understand your needs. All types of call girls like Housewives, College girls,#J11 Russian girls, Muslim girls, Afghani girls, Bengali girls, Working girls, south Indian girls, Punjabi girls, etc. In-Call: — You Can Reach At Our Place in Bangalore Our place Which Is Very Clean Hygienic 100% safe Accommodation. Out-Call: — Service for Out Call You have To Come Pick The Girl From My Place We Also Provide Door-Step Services Hygienic: — Full Ac Neat And Clean Rooms Available In Hotel 24 * 7 Hrs In Bangalore Our Services and Rates: – One Shot — 2500/in call (time ½ hour), 5000/out call Two shot with one girl — 5000/in call (time 1 hour), 6000/out call Body to body massage with sex- 3000/in call (time 1 hour) full night for one person– 8000/in call, 10000/out call (shot limit 4 shot) We are available 24*7 all days of the year Call us — 6378878445 !! Thank you for Visiting.

Race Course Road } Book Call Girls in Bangalore | Whatsapp No 6378878445 VIP ...

dishamehta3332

💚Chandigarh Call Girls Service 💯Piya 📲🔝8868886958🔝Call Girls In Chandigarh No💰Advance Cash On Delivery Service Chandigarh Call Girls Service punjab ❤️🍑 📲Lucky 8868886958📲 💚👄🫦 Independent Escort Service Chandigarh Call Now :- 8868886958 Lucky Call Girl In Chandigarh | Chandigarh Call Girl | Call girl service in Chandigarh | Call Girls In Chandigarh | Chandigarh Call Girls Their services range from erotic encounters and movie dates to in-call and out-call services, making this option available 24/7. Available for services including NSA, threesomes and foursomes sessions as well as massage services and casual foreplay - they even provide real girlfriend experience. Find one online or visit local women's clubs, hotels or restaurants. Hiring a Chandigarh call girl for an evening or day out can be the perfect addition to your social gathering or office event, or you could arrange for her to visit your home or hotel room. Not only are these women gorgeous, they're intelligent as well, with great senses of humor - sure to please and leave you wanting more. If you want a cheap escort in Chandigarh, look for someone who is either a student or works part time so that she will always be available when you need her. In addition to this, look for housewives as this ensures they have stable lives that can keep you satisfied for extended periods. These beautiful ladies will capture your attention at first sight with stunning eyes and full, seductive lips; not to mention a seductive personality that makes you want to spend more time with them; moreover they are discreet enough to meet up anywhere nearby! Hiring a call girl in Chandigarh can be done through either the internet or calling her directly, with services like massage or sex sessions offered to request from specific agencies within a few hours of making contact. Furthermore, text the girl directly for price quotes!

💚Chandigarh Call Girls Service 💯Piya 📲🔝8868886958🔝Call Girls In Chandigarh No...

Sheetaleventcompany

Kolkata Call Girls Shobhabazar 💯Call Us 🔝 8005736733 🔝 💃 Top Class Call Girl Service Available Call Mrs Leela Ji +91-8005736733 We offer all types of girls of your choice with space. Our escorts are fully cooperative and understand your needs. All types of call girls like Housewives, College girls,#J11 Russian girls, Muslim girls, Afghani girls, Bengali girls, Working girls, south Indian girls, Punjabi girls, etc. In-Call: — You Can Reach At Our Place in Kolkata Our place Which Is Very Clean Hygienic 100% safe Accommodation. Out-Call: — Service for Out Call You have To Come Pick The Girl From My Place We Also Provide Door-Step Services Hygienic: — Full Ac Neat And Clean Rooms Available In Hotel 24 * 7 Hrs In Kolkata C010524HD Our Services and Rates: – One Shot — 2500/in call (time ½ hour), 5000/out call Two shot with one girl — 5000/in call (time 1 hour), 6000/out call Body to body massage with sex- 3000/in call (time 1 hour) full night for one person– 8000/in call, 10000/out call (shot limit 4 shot) We are available 24*7 all days of the year Call us — 8005736733 !! Thank you for Visiting.

Kolkata Call Girls Shobhabazar 💯Call Us 🔝 8005736733 🔝 💃 Top Class Call Gir...

Namrata Singh

In this captivating lecture, Dr. Faiza, an esteemed Assistant Professor of Physiology, embarks on a comprehensive journey into the multifaceted realm of local blood flow regulation. With meticulous detail and clarity, she unravels the intricate mechanisms that govern the dynamic balance between tissue perfusion and vascular resistance, shedding light on both acute and chronic aspects of blood flow control. Beginning with an exploration of acute influences, Dr. Faiza elucidates how physiological factors such as metabolic demand, myogenic responses, and autoregulatory mechanisms orchestrate rapid adjustments in local blood flow. Students gain insight into the vasodilator theory, which elucidates the role of metabolic byproducts and vasoactive metabolites in promoting vasodilation, alongside the oxygen demand theory, which underscores the interplay between tissue oxygenation and nutrient demand. Delving deeper, the lecture delves into the fascinating realm of humoral control, where hormones and vasoactive substances wield significant influence over vascular tone. Dr. Faiza navigates through the intricacies of endothelial-derived factors like nitric oxide (NO) and histamine, alongside hormonal regulators such as angiotensin II and vasopressin. Through vivid explanations and illustrative examples, she unveils the intricate dance of vasodilation and vasoconstriction orchestrated by these biochemical messengers. Moreover, the lecture extends its gaze to the extrinsic control of blood flow, where sympathetic innervation exerts a profound impact on vascular dynamics. Dr. Faiza elucidates the role of sympathetic tone in modulating vascular resistance, highlighting its implications in diverse physiological and pathological scenarios. From skin perfusion to coronary circulation, students gain a nuanced understanding of how neural inputs shape local blood flow patterns. Enriched with clinical insights and contemporary research findings, this lecture equips students with a holistic understanding of blood flow regulation. By exploring concepts like active and reactive hyperemia, vascular remodeling, and collateral circulation, Dr. Faiza fosters a deeper appreciation for the adaptive responses of the cardiovascular system to changing physiological demands and pathological insults.

Control of Local Blood Flow: acute and chronic

MedicoseAcademics

Call Girl In Indore 📞9235973566📞 Just📲 Call Inaaya Indore Call Girls Service In Indore No💰Advance Cash On Delivery Service "Call Girls Indore VIP Call Girls Service Indore.. Booking Open Now We Are Providing Safe & Secure High Class girl women sucking men Services Affordable Rate 100% Satisfaction, Unlimited Enjoyment. Any Time for Model/ women seeking men in royal call girl High class luxury and premium call girl agency. ✔️High class luxury and premium escorts agency We Provide Well Educated, Royal Class Female, High-class Escorts agency offering a top high class escort service in the royal Escorts ✔️ Get High Profile queens , Well Educated , Good Looking , Full Cooperative Model Services. you can see me at my comfortable Hotels or I can visit you in hotel Our Service Available IN All Services 3/5/7 Star Hotels, In call /Out call Service 24/7.. ✔️ All Meetings We Provide Hottest Female With Me Are Safe And Consensual With Most Limits Respected Complete Satisfaction Guaranteed...Service Available In:- 24/7 3 * 5 *7 *Star Hotel Service In. In Call Out call service Avilable also. ✔️ I guarantee you to have an unforgettable experience with me A curvy body, long hair and silky smooth skin. She is an independent royal Escorts/Women Seeking Men model will give you more pleasure & Full satisfaction. ✔️ I am very sensual and flirtatious with charming personality! I love to laugh and my bright smile is ever Present. ,Hotel & Home Services CALL PLZZ ✔️Available Near All 3* 4* 5* 7* Hotels Of I Want Only Hotel Name , Guest Name , Room No. Only For Confirmation.✔️ Nandani... agency...⭐⭐⭐⭐⭐ VIP...Service ✣ ✤ ✥ ✦ TIME WASTERS AND BARGAINERS ARE PLEASE EXCUSE, WE RESPECT YOUR SAFETY AND PRIVACY AND EXPECT TH WHATSAPP: 9235973566 CALL ME" 9235973566

Call Girl In Indore 📞9235973566📞 Just📲 Call Inaaya Indore Call Girls Service ...

Sheetaleventcompany

Recently uploaded (20)