text:
a Knowledge Summary by
Rebecca Littlehales BVSc MRCVS 1*
1University of Liverpool, Chester High Road, Neston, CH64 7TE
*Corresponding Author (beckylittlehales@gmail.com)
Vol 5, Issue 4 (2020)
Reviewed by: Jodie Hughes (BVSc CertAVP(VA) FHEA Dip.ECVAA MRCVS) and William McFadzean (BVetMed CertAVP(VA) DipECVAA MRCVS)
Next review date: 23 Apr 2022
PICO question
In dogs undergoing elective procedures does the use of medetomidine during premedication result in an increase in anaesthetic complication rates, when compared to acepromazine?
Clinical bottom line
Category of research question
The number and type of study designs reviewed
Four papers were critically reviewed, all of which were randomised controlled trials
Strength of evidence
Outcomes reported
There were some statistically significant differences between using medetomidine and acepromazine as premedications in the outcomes measured, but as the clinical parameters including blood pressure were still within acceptable clinical limits, the clinical benefits of these findings remain undetermined. There is also evidence to suggest that patients premedicated with medetomidine have less of a perioperative stress response than those receiving acepromazine, but in addition may have increased risk of cardiac conduction disturbances, but the clinical importance of these findings is also unknown
The overall findings showed that either drug can be used as a suitable premedication, but the differences in pain score postoperatively shown in one small study mean that due to its poor analgesic properties it is recommended when using acepromazine instead of medetomidine, that additional analgesia should be given to reduce postoperative pain for better animal welfare
How to apply this evidence in practice
The application of evidence into practice should take into account multiple factors, not limited to: individual clinical expertise, patient's circumstances and owners' values, country, location or clinic where you work, the individual case in front of you, the availability of therapies and resources.
Knowledge Summaries are a resource to help reinforce or inform decision making. They do not override the responsibility or judgement of the practitioner to do what is best for the animal in their care.
Clinical scenario
Premedications are often used in anaesthetic protocols for dogs undergoing elective procedures, with acepromazine and medetomidine being commonly used in combination with other drugs. These two drugs belong to different classes of anaesthetic drugs, with acepromazine being a phenothiazine whilst medetomidine is an alpha-2 adrenergic receptor agonist. This summary aims to determine if there are any differences in anaesthetic complication rates between these two drugs, so that veterinary surgeons in practice are more informed on which would be best to use in their anaesthetic protocols for the best patient outcome.
Four blinded controlled trials (Grint et al., 2010; Väisänen et al., 2002; Väisänen et al., 2005; and Wamaitha et al., 2019) were found to be relevant to the PICO question, which have strong study designs. The Wamaitha et al. (2019) study compared the two drugs when used as a premedication in combination with an induction using ketamine and propofol. The outcomes measured in the study that were relevant to the PICO question were postoperative pain scoring and smoothness of recovery based on time to standing and whether they had tremors when recovering, and post induction apnoea. The Grint et al. (2010) study provided a larger, more representative sample size and compared the two drugs when used in combination with buprenorphine as a premedication. The outcomes measured in this study were more based around cardiopulmonary parameters as a measure of anaesthetic complications, which were considered less in the Wamaitha et al. (2019) study. The two studies by Väisänen et al. (2002 & 2005) were conducted concurrently using the same study design, one (2002) to compare the perioperative stress response between acepromazine and medetomidine as a premedication based on anaesthesia monitoring data, blood hormone concentrations, heart rates and mean arterial pressure and assessment of pain and distress. The other study (2005), compares the electrocardiography data of the same cohort focusing on heart rate, cardiac conduction disturbances and heartbeat variability data.
Grint et al. (2010)
Population: Dogs were enrolled in the study at the University of Liverpool's Small Animal Hospital in a 2-year period who were undergoing routine surgical or diagnostic procedures that involved only a mild to moderate stimulus such as neutering, arthroscopy, endoscopy, radiography and other similar minor procedures. Only dogs with an American Society of Anaestheologists (ASA) status of 1 (healthy) or 2 (mild systemic disease) were included in the study.
Sample size:
90 dogs (two dogs from Group 1 were lost so were not analysed, and no explanation is given for this)
Intervention details: The dogs were randomly assigned (by block randomisation and sealed envelopes) to one of three groups.
Group 1 (28 dogs) were given acepromazine (0.03 mg/kg) and buprenorphine (0.02 mg/kg) intramuscularly.
Group 2 (30 dogs) were given medetomidine (5 µg/kg) and buprenorphine (0.02 mg/kg) intramuscularly.
Group 3 (30 dogs) were given medetomidine (10 µg/kg) and buprenorphine (0.02 mg/kg) intramuscularly.
Experimental procedure:
Before administration of any premedications, a full clinical examination was performed, and sedation score was recorded for each dog.
The premedications were given in a single syringe according to the treatment group that the dog was assigned to and were administered into the dog's cervical epaxial muscle by a veterinary surgeon or veterinary nurse. The dogs were then observed for any adverse effects.
After 15 minutes (Group 1) or 30 minutes (Groups 2 and 3) in line with the peak sedation effect time of the drugs used, respiratory rate, pulse rate and sedation score were then recorded.
A cephalic catheter was placed in all dogs and anaesthesia was induced using IV propofol until the dogs' jaw tone was relaxed and the tongue could be held without retraction. Previous research was used to predict the required dose of propofol needed for induction. Group 1 were administered propofol using a syringe driver at 2.25 mg/kg/min, Group 2 at 1.5 mg/kg/min and Group 3 at 0.75 mg/kg/min.
An endotracheal tube was placed and anaesthesia was maintained using isoflurane in oxygen with a specified appropriate breathing system (parallel lack anaesthetic circuit for dogs weighing >10 kg with fresh gas flow equal to minute ventilation and a Jackson-Rees modified Ayre's T-piece for dogs weighing <10 kg with fresh gas flow equal to at least 2x minute ventilation). Anaesthesia was maintained at a specified standard depth throughout.
Intravenous fluid therapy (Hartmann's) was administered throughout at 10 ml/kg/hour, and additional analgesia of carprofen at 4 mg/kg was administered intravenously if required.
Monitoring throughout the anaesthetic period involved oxygen saturation (using a pulse oximeter and lingual probe), end tidal partial pressure carbon dioxide concentration (using a capnograph), oscillometric blood pressure measurements (using dorsal pedal or palmar carpal arteries), pulse rate and respiratory rate. These values were all recorded at 5 minute intervals.
There were protocols in place should dogs develop hypotension or bradycardia, but none of the dogs required this treatment.
At the end of the procedure, isoflurane was stopped. For Groups 2 and 3 if the procedure length was <120 minutes atipamezole was given intramuscularly at the same time as stopping the isoflurane (Group 2 at 0.025 mg/kg and Group 3 at 0.05 mg/kg).
Dogs were continually monitored during recovery, where times from discontinuing isoflurane to extubation, movement to sternal recumbency and standing and walking were recorded.
Study design: Randomised, blinded, controlled trial
Outcome Studied:
Sedation scores
Median dose of propofol used
Mean vaporiser setting
Duration of anaesthesia
Adverse effects post premedication
Mean, diastolic and systolic blood pressure
Heart and respiratory rates
Mean end tidal partial pressure of carbon dioxide
Time from isoflurane discontinuation to extubation, moving to sternal recumbency, standing and walking
Main Findings
(relevant to PICO question):
Group 1: salivation (1/28), signs of pain on injection (1/28)
Group 2: salivation (2/30), signs of pain on injection (1/30), muscle twitching (1/30)
Group 3: signs of pain on injection (4/30), salivation (3/30), vomiting (3/30), muscle twitching (2/30)
Mean and diastolic blood pressure was significantly lower for dogs in Group 1 compared to those in Groups 2 and 3
Mean and lowest heart rates were significantly higher for dogs in group 1 compared to those in Groups 2 and 3
Respiratory rates were significantly higher for dogs in group 1 compared to those in Groups 2 and 3
Mean end partial pressures of carbon dioxide
Mean values were significantly lower for dogs in Group 1 compared to the other groups, but all values were within normal range
No record of how dogs were assessed as to whether they needed additional analgesia, or how many of the dogs were given carprofen as a treatment for this.
The difference in the amounts of propofol and isoflurane administered depending on the group may have confounded the mean arterial pressure values.
Tissue perfusion was not measured which may have helped to explain the clinical significance of the differences in mean arterial blood pressures.
The dose of medetomidine used in Group 2 is lower than the licenced dose range as stated by the datasheet, so at this dose it used off-licence.
There are two dogs' data which was not analysed as it was lost and no explanation is given for this.
Väisänen et al. (2002)
Population: Dogs that underwent routine elective ovariohysterectomy at Helsinki University Veterinary Teaching Hospital between January and August 2000. Inclusion criteria required the dogs to have a good body condition score, weigh between 15 and 40 kg, be 2–7 years old and not on any medications. Brachycephalic and Greyhound-type breeds were excluded. The dogs were determined to be in good health based on a thorough clinical examination, and haematology and biochemistry blood analysis. The age and body weights of the dogs in the two different groups did not differ significantly.
Sample size: 42 dogs (this was initially 44 dogs, but two dogs were omitted in the results due to technical difficulties)
Intervention details:
The method of allocating the dogs into the two treatment groups was using sealed envelopes.
Group MED (21 dogs) were given medetomidine (20 µg/kg) and butorphanol tartrate (0.2 mg/kg), intramuscularly.
Group ACE (21 dogs) were given acepromazine maleate (0.05 mg/kg) and butorphanol (0.2 mg/kg), intramuscularly.
Experimental procedure
On the day of the procedures, the dogs arrived at or before noon and stayed in the clinic for 24 hours. On arrival each dog was placed in a separate cage in a quiet area and were only handled by the experimental team.
After around 1 hour of time spent in the cage, the premedication was administered. The premedications were all in covered syringes of equal volumes, and were administered into the biceps femoris muscle by the same trained investigator who was unaware of the medication given to each dog, but was aware of the two possibilities.
The dog was then left undisturbed for 15–20 minutes.
Then a jugular catheter (for blood sample collection) and femoral artery catheter (for continuous direct measurement of blood pressure) were placed using local anaesthetic.
Cephalothin (30 mg/kg, IV) and carprofen (4 mg/kg, IV) were administered before induction of anaesthesia. An infusion of lactated Ringer's solution (10 ml/kg/h, IV) was started, and the infusion was continued until the end of surgery.
Anaesthesia was then induced using propofol in small increments over a 90 second period to allow orotracheal intubation, and the amount required was recorded.
Anaesthesia was maintained by using isoflurane in oxygen (flow rate of 1 L/min) through a semi-closed circle. At least 10 minutes elapsed from induction to commencing the surgery.
Ovariohysterectomy was performed via a routine standard ventral midline approach by one of three experienced veterinary surgeons.
During anaesthesia, heart rate, direct arterial blood pressure, end-tidal CO2 (ETCO2), and end-tidal isofluorane concentrations, respiratory rate, and arterial haemoglobin saturation (via an oxygen saturation (SpO2) measurement using a probe on the dog's tongue) were measured continuously. Arterial blood samples were obtained just prior to induction and at the end of surgery for measurement of partial pressure of oxygen (PaO2), partial pressure of carbon dioxide (PaCO2), and pH.
Dogs could breathe spontaneously, but respiration was assisted manually when necessary to maintain ETCO2 <60 mm Hg. Additional boluses of fluids (5–10 ml/kg, IV) were administered to prevent hypotension (mean arterial blood pressure [MAP] <60 mmHg). Heating blankets were used to maintain rectal temperature at ≥ 37 C.
After finishing the surgery, buprenorphine (0.010 mg/kg) was administered IV, then the dogs were maintained in a light plane of anaesthesia for 15 minutes while the femoral artery catheter was removed. The vaporiser was then turned off, and the dogs could breathe pure oxygen for 5 minutes. The duration of preoperative sedation, anaesthesia, and surgery was recorded.
The dogs were recovered in their cages and time until extubation was recorded. Dogs that became excited during recovery were given propofol (2–4 mg/kg, IV) and buprenorphine (0.005 mg/kg, IV). Physical examinations were performed at predetermined time points, and additional warming was provided when needed, to maintain rectal temperature ≥ 37o Buprenorphine (0.010 mg/kg, IV) was used for postoperative analgesia when required.
Throughout the study, each dog wore an ambulatory electrocardiographic monitor (Holter monitor), and the behavior was video recorded. Results of the Holter monitoring and behavioural analysis were not evaluated in this study.
Hormone concentration measurements were obtained from the jugular vein and collected in EDTA (Ethylenediaminetetraacetic acid) tubes. Plasma was separated by refrigerated centrifugation within 30 minutes of collection. Concentrations of epinephrine, norepinephrine, cortisol, and β-Endorphin were measured via methods described in the paper. Samples that had catecholamine concentrations less than the limit of detection were assigned a value equal to the limit of detection. The first blood samples were obtained at time of arrival via jugular venipuncture. The subsequent samples immediately prior to induction, within 2 minutes of removal of the second ovary, end of the surgery, 1, 3 and 6 hours post surgery and 24 hours after the initial sample were taken via the indwelling catheter. Blood volume was replaced by giving a bolus of 20 ml of lactated Ringer's solution and heparinised saline solution was used to prevent clotting of the catheter between samples.
Heart rate was measured by pulse palpation immediately before administration of preanaesthetic medication and 1, 3, and 6 hours after surgery. In addition, intraoperative heart rate and MAP (directly measured) were recorded immediately prior to induction, 10 minutes after induction, at the time of the abdominal incision, at time of removal of each ovary, during closure of the incision, and at the end of surgery.
Response of each dog to handling was recorded during the entire perioperative period. Sedation and pain and distress scores were determined immediately before administration of preanaesthetic medication and after surgery at the same times as collection of blood samples for hormonal analysis. Assessments were performed for each dog after other measurements and collection of samples were completed. Sedation was assessed initially by monitoring each dog's response to opening of the door to the cage, hand clapping, and speaking to the dog. For pain and distress evaluation, vocalisation, restlessness, freedom of movement, and finally, response to firm pressure applied to the region of the incision were observed. The protocol used was a modification of scoring systems that are described elsewhere in literature.
Anaesthetic variables (duration of perioperative sedation, duration of anaesthesia, mean duration of surgery, and mean interval from the end of surgery until extubation, amount of propofol required, end-tidal isoflurane concentration, pH and SpO2, PaO2 and PaCO2, additional fluids required, additional propofol and buprenorphine required to treat excitation during recovery).
Blood hormone concentrations (concentrations of epinephrine, norepinephrine, cortisol, and β-Endorphin).
Heart rate and MAP throughout.
Assessment of pain and distress (by response to handling, sedation assessment, pain and distress score via a described protocol).
Anaesthetic variables
Group ACE required significantly more propofol for induction of anaesthesia (mean of 3.6 ± 0.7 mg/kg), compared with Group MED (mean of 1.3 ± 0.2 mg/kg).
Mean end-tidal isoflurane concentration (ETISO) was significantly higher during anaesthesia for the Group ACE (mean of 1.6 ± 0.2%), compared with Group MED (mean of 1.4 ± 0.3%).
11 dogs in Group ACE were given additional fluids (ranging from 5–10 ml/kg; mean of 6 ml/kg) at the beginning of anaesthesia; none of the dogs in the MED group received any additional fluids.
Blood hormone concentrations
Plasma concentrations of epinephrine and norepinephrine were significantly lower in Group MED, than Group ACE. The values for Group MED decreased to a lower concentration and increased at a later time point than Group ACE also.
Concentration of cortisol was significantly lower for Group MED, compared with Group ACE; however, the cortisol concentration increased during surgery in both groups and remained at or above the concentration of the initial sample until collection of the sample at 24 hours.
Heart rate and MAP
Heart rate was significantly lower and MAP significantly higher in Group MED, compared with values for Group ACE.
The MAP decreased significantly after induction of anaesthesia in both groups, but values did not differ between groups during surgery.
Assessment of pain and distress
Signs of sedation were apparent for a longer period in Group ACE, with the sedation scores being significantly higher for Group ACE than for Group MED 3 and 6 hours after completion of surgery.
Group MED had higher pain and distress scores throughout the entire assessment period, compared with Group ACE, but the values were only significantly different 6 hours after surgery.
Small sample size of 42 dogs split into two groups, which may not be representative of the total dog population, and it was not stated by the researchers what the required sample size should be for adequate study power. Therefore, this may affect the reliability of the conclusions made.
Population: Dogs that underwent routine elective ovariohysterectomy at Helsinki University Veterinary Teaching Hospital between January and August 2000. Inclusion criteria required the dogs to have good body condition, weigh between 15 and 40 kg, be 2–7 years old and not on any medications. Brachycephalic and Greyhound-type breeds were excluded. The dogs were determined to be in good health based on a thorough clinical examination, and haematology and biochemistry blood analysis. The age and body weights of the dogs in the two different groups did not differ significantly.
43 dogs (although there were technical errors which led to some data from both groups not being analysed; this is fully explained in the results section of the study)
The dogs were randomly allocated to the two treatment groups by the method of sealed envelopes.
Group MED (21 dogs) were given medetomidine (0.02 mg/kg) and butorphanol tartrate (0.2 mg/kg), intramuscularly.
On the day of the procedures, the dogs arrived at or before noon and stayed in the clinic for 24 hours. On arrival each dog was fitted with an ECG (echocardiogram) Holter monitor and placed in a separate cage in a quiet area and were only handled by the experimental team.
After around 1 hour of time spent in the cage, the premedication was administered. The dog was then left undisturbed for 15–20 minutes.
Then a jugular catheter (for blood sample collection) and femoral artery catheter (for continuous direct measurement of blood pressure) were placed whilst the dogs were in lateral or dorsal recumbency with minimal or no restraint. Carprofen (4 mg/kg, IV) was administered before induction of anaesthesia.
Anaesthesia was then induced 85 minutes post premedication, using propofol. Mean ± SD dosage of propofol was 1.3 ± 0.2 mg/kg IV, for dogs premedicated with medetomidine and 3.6 ± 0.7 mg/kg IV, for dogs premedicated with acepromazine.
Anaesthesia was maintained by using isoflurane in oxygen, mean ± SD (standard deviation) end-tidal isoflurane concentration during anaesthesia was 1.4 ± 0.3% for dogs premedicated with medetomidine and 1.6 ± 0.2% for dogs premedicated with acepromazine.
During anaesthesia, end-tidal partial pressure of CO2 (ETCO2) was maintained at < 60 mmHg by use of intermittent manual ventilation. Oxygen saturation as measured by pulse oximetry remained between 99% and 100% and mean arterial blood pressure remained > 60 mm Hg throughout surgery in all dogs. Rectal temperature was maintained at ≥ 37oC by use of heating blankets.
After finishing the surgery, buprenorphine (0.010 mg/kg) was administered IV and the duration of preoperative sedation, anaesthesia, and surgery was recorded.
The dogs recovered in their cages and time until extubation was recorded. Dogs that became excited during recovery were given propofol (2–4 mg/kg, IV) and buprenorphine (0.005 mg/kg, IV). In seven dogs (two in Group ACE and five in Group MED), an additional dose of buprenorphine (0.01 mg/kg, IV) was administered 6 hours after surgery. Physical examinations were performed at predetermined time points, and additional warming was provided when needed, to maintain rectal temperature ≥ 37o.
6 hours post surgery the dogs were given food and water and taken for a walk. After this, the dogs were taken for walks and physical examinations were performed at predetermined intervals. Around 24 hours after admission, ambulatory electrocardiography was discontinued, and dogs were discharged.
The ambulatory electrocardiography equipment used involved five adhesive electrodes that were used to obtain two transthoracic leads. To allow an assessment of the relationship between cardiac activities and perioperative events, the clock of the Holter monitor was synchronised with one worn by one of the members of the investigative team and with the clock on the video recorder used to record the dogs' behaviour when in their cages.
A standard Holter analysis system was used to analyse ambulatory ECGs and determine hourly minimum, maximum, and average heart rates; number of episodes of second- and third-degree atrioventricular block; number of ventricular premature complexes (VPCs); and number of sinus pauses > 2.0 seconds long. To more closely evaluate heart rate behaviour, printouts of heart rates recorded every 2 minutes were also obtained. Analyses were conducted by a physician accustomed to reading canine ECGs. Full disclosure printouts were checked by a veterinarian and verified by a veterinary cardiologist to ascertain correct labelling of arrhythmic events. The in-depth methods of ECG analysis are detailed in full in the study methods.
Study design: Randomised controlled trial
Cardiac conduction disturbances
Heartbeat variability
Additional observations (lying down time)
Minimum heart rate during the 24 hour recording period was significantly lower among dogs in Group MED (mean of 38 beats/min; 95% CI, 35–40 beats/min) than in Group ACE (mean of 48 beats/min; 95% CI, 45–51 beats/min). This was mainly attributed to low heart rates during the preoperative sedation phase and within the first few hours after surgery in dogs given medetomidine.
The number of episodes of second-degree atrioventricular (AV) block was significantly greater among dogs in Group MED than in Group ACE. In the dogs in Group MED the episodes of atrioventricular block were mostly in the 30 minutes following premedication. Both Mobitz type I and II types of second-degree AV block were seen, but third-degree atrioventricular block was not identified in any of the dogs (Kashou et al., 2020).
The number of dogs that had sinus pauses > 2.0 seconds and median duration of the longest pauses were significantly greater among Group MED (20 dogs; median duration of longest pause, 3.5 seconds; range, 2.2–7.5 seconds) than in Group ACE (14 dogs; median duration of longest pause, 2.5 seconds; range, 2.1–5.5 seconds). In Group MED, pauses occurred most often during the preoperative sedation or early recovery period. In Group ACE, pauses occurred most often during the night.
In the time up until 6 hours post surgery, the time domain HRV (Heart Rate Variability) indices (SD of all normal-to-normal R-R intervals, square root of the mean squared differences of successive normal-to-normal R-R intervals, and proportion of interval differences for successive normal-to-normal R-R intervals > 50 milliseconds) were significantly higher among Group MED than in Group ACE.
However, intraoperative time domain HRV indices were lower and the LF:HF (Low Frequency: High Frequency) ratio was significantly higher among Group ACE than Group MED.
It is stated that this study was conducted alongside a previous study conducted by the author (Väisänen et al., 2002), however there are differences in the described experimental procedure, this leads to ambiguity. Most importantly in relation to this, in this study it does not suggest that the study was blinded, whereas Väisänen et al. (2002) suggests that the investigator was blinded.
There is a lack of control 24-hour electrocardiography recordings available to compare these results to, especially when considering the arrhythmias that occurred during the night in the study.
The calculations of heartbeat variability included measurements during the periods of arrhythmia which affects their accurate estimation.
Wamaitha et al. (2019)
Population: Dogs were recruited from willing owners within the area of the Faculty of Veterinary Medicine, University of Nairobi, Kenya and had to be free of clinical disease.
Sample size: 12 male mongrel dogs
12 dogs split into Group A (six dogs) and Group B (six dogs) randomly by computer random number generator.
Group A involved intramuscular sedation using acepromazine (0.1 mg/kg bodyweight) then induction and maintenance of anaesthesia using intravenous 4 mg/kg ketofol (1:1 ratio of ketamine and propofol).
Group B involved intramuscular sedation using medetomidine (0.02 mg/kg bodyweight) then induction and maintenance of anaesthesia using intravenous 4 mg/kg ketofol (1:1 ratio of ketamine and propofol).
Dogs were housed at the Department of Clinical Studies in individual kennels for 2 weeks of acclimatisation before the study began and were fed a commercial dog food once daily with ad libitum water.
They were all wormed using a combined praziquantel, pyrantel pamoate, fenbental product (Vermic Total®) plus given ectoparasite control consisting of chlorfenvinphos (Steladone®) once per week.
During this 2-week acclimatisation period the dogs were regularly handled, and clinical examinations performed weekly.
Food and water were withheld 12 hours prior to the procedure.
Each dog was weighed using digital scales and sedation and pain scores, pedal and palpebral reflexes were assessed before they were sedated.
The dogs were then sedated according to whether they were in Group A or B and the investigator was blinded to this process to reduce bias.
At 10 minutes post sedation, a cephalic intravenous catheter was placed, then the scrotal area was shaved, scrubbed and disinfected with 70% ethyl alcohol.
At 30 minutes post sedation, anaesthesia was induced using ketofol and an endotracheal tube was placed.
The anaesthetic monitoring was supported using a multi-parameter machine.
A standard dose of ketofol (50% of induction dose) was administered when the laryngeal reflex was restored, indicated by coughing. Another dose (25% of induction dose) was drawn up for use if needed throughout the anaesthetic period.
Orchidectomy was performed routinely, with warmed lactated Ringer's solution administered intravenously through the catheter at 10 ml/kg/hr throughout the surgery until extubation.
The sedation score was measured every 5 minutes from the injection of sedation using a protocol described by Tsai et al. (2013) and were measured for post induction apnoea.
Palpebral (by running a finger along the dog's eyelashes) and pedal (by firm pressure on interdigital skin of either hindlimb) reflexes were measured throughout the anaesthetic period.
The endotracheal tube was removed when the laryngeal reflex (indicated by coughing) returned and dogs were monitored in recovery.
Postoperative pain score – assessed using the Short Form Glasgow Composite Pain Scale (Reid et al., 2007). It was measured at 1, 2, 4, 8 and 24 hours postoperatively. If the pain score was ≥13 out of a total of 24 at any point, the dog was excluded from the study and given intramuscular phenylbutazone at 8 mg/kg.
Sedation score (using protocol described by Tsai et al., 2013).
Duration of anaesthesia.
Smoothness of recovery – based on number of attempts to stand and presence of tremors or not.
(relevant to PICO question): Postoperative pain score
In the second hour postoperatively, dogs in Group A had significantly (p=0.01) higher pain scores (median of 8) compared to dogs in Group B (median of 6).
In the fourth hour postoperatively, dogs in Group A had significantly (p=0.01) higher pain scores (median of 7) compared to dogs in Group B (median of 6).
In the eighth hour postoperatively, dogs in Group A significantly (p=0.004) higher pain scores (median of 6.5) compared to dogs in Group B (median of 4.5).
At the end of the monitoring period (24 hours postoperatively), dogs in Group A had significantly (p=0.01) higher pain scores (median of 5.5) compared to dogs in Group B (median of 2.5).
Smoothness of recovery
Dogs in Group B had a significantly longer (p<0.01) extubation time compared to those in Group A.
Dogs in Group A took longer to stand (37.2 minutes ±7) than those in Group B (17 minutes ± 7.1) which was statistically significant (p=0.04).
The pedal reflex was absent for a longer period in the dogs in Group B (50 minutes) compared to those in Group A (10 minutes), which was statistically significant (p=0.01).
The palpebral reflex was absent for a longer period in the dogs in Group B (30 minutes) compared to those in Group A (5 minutes), which was statistically significant (p=0.04).
83% (5/6) of dogs in Group A exhibited tremors on recovery compared to 33% (2/6) of dogs in Group B.
Cardiorespiratory assessment
67% of dogs given medetomidine showed post induction apnoea, compared to 33% of dogs given ACP. No individual numbers of dogs used to calculate these percentages are stated in the study.
The paper did not analyse any variations in age or weight of the dogs in the two groups.
No values given for extubation time for both treatment groups.
No evaluation of cardiorespiratory parameters pre, peri or postoperatively.
Many of the comparisons of values that show differences in outcomes are not statistically significant.
Some outcomes have percentages given but it is not specified as whether they were found to be statistically significant or not.
The pain score cut off used for rescue analgesia in this study was greater than or equal to 13/24, whereas in clinical practice a much lower cut off may be used.
It is not clear whether the investigator conducting the observations/pain scores was consistent throughout, or whether there were multiple observers as this could lead to inconsistent assessment of the dogs.
Appraisal, application and reflection
When appraising the evidence on this topic it became clear that there were only four papers that directly compare the use of medetomidine and acepromazine in a randomised control trial study design. Any other study design was deemed not relevant to the PICO question as studies with different intervention protocols cannot be directly compared. It is also important to consider what is defined as an 'anaesthetic complication', as this may vary based on different studies. According to one study looking into the incidence of cardiorespiratory anaesthetic complications, (in descending order of incidence) bradycardia, hypotension, hypoventilation, hypoxia, hypothermia and death were the most common (Redondo et al., 2007). A rapid, smooth and complete recovery is advantageous in veterinary patients, especially in outpatient procedures such as neutering (Laing et al., 2009). An important aspect of this is peri and postoperative pain which can contribute to a poor recovery, and cardiorespiratory complications also occur in recovery (Lerche et al, 2000).
In the first study evaluated (Grint et al., 2010) it was shown that medetomidine maintained blood pressure better than acepromazine, but whether this has any clinical benefit was not studied. This could have potentially been assessed by measuring tissue perfusion which was not done in the study and would have improved the clinical relevance. However, the practicalities of this would be difficult in a clinical setting with there being no readily available clinical equipment to measure this or available normal values for comparison; and it would have to be determined which tissue or tissues were relevant to study. It was also found that mean and lowest heart rates perioperatively were significantly higher for dogs given acepromazine, compared to those given medetomidine, which may be because acepromazine has no analgesic properties (Thurmon et al., 1996; and Smith et al., 2001). This may also be due to alpha-2 adrenergic receptor agonist drugs such as medetomidine often causing a decrease in heart rate of patients due to its pharmacological effects on blood pressure (Murrell, 2016). Overall, the study had strong methodology due to the randomised controlled trial design with a large sample size and had minimal limitations because of this, therefore the results are highly applicable to the overall dog population. However, the study did not fully explain the clinical conditions of the dogs who were judged to have an ASA status of 2 (mild systemic disease) but this may have had a confounding effect on the outcomes (Abouleish et al., 2015). There were also differences in the amounts of propofol and isoflurane administered between the groups which could have confounded the mean arterial pressure values as propofol has hypotensive effects due to resetting of baroreceptor sensitivity so reflex tachycardia often does not occur (Grood et al., 1987) plus isoflurane causes dose-dependent cardiovascular depression and a reduction of blood pressure (Lynch, 1986).
In the second study evaluated (Väisänen et al. (2002), it was found that plasma concentrations of epinephrine, norepinephrine and cortisol levels were significantly lower in the group receiving medetomidine than those given acepromazine. This would suggest that medetomidine elicits a reduced perioperative stress response when administered compared to acepromazine, however the medetomidine group did have significantly higher pain and distress scores than the acepromazine group 6 hours post surgery. It is proposed that an increased stress response could be a factor in patient morbidity during anaesthesia (Desborough, 2000), so this study suggests that medetomidine would be better as reducing this risk. A limitation of this study was the sample size; by using only 42 dogs split into the two groups, it may not be representative of the normal dog population. It was also not stated by the researchers if any statistical power calculations were carried out in order to work out an adequate sample size to use. It is also worth noting that the authors used either acepromazine or medetomidine in combination with butorphanol as the premedication in the study; butorphanol is a opioid with only mild analgesic effects at the doses given in the study (Grimm et al., 2000). Therefore, acepromazine and butorphanol as a premedication would provide very little analgesia to the patient. Due to this, opioids with more potent analgesic properties should ideally be used for surgical procedures, such as methadone or buprenorphine. It has been suggested by research that pre-emptive analgesia is much more effective than giving peri or postoperative analgesia like this study did (Dahl et al., 2005). This may have affected the results, as having more appropriate increased analgesia may have had a differing effect on the variables measured, especially heart rate.
In the third study evaluated (Väisänen et al. (2005), it was found that heart rates were significantly lower during the 24-hour monitoring period for those dogs administered medetomidine compared to those given acepromazine, however this is not surprising given the pharmacological effects of medetomidine as alpha2-agonists often cause bradycardia due to their effects on blood pressure (Murrell, 2016). In those given medetomidine, there were significantly greater number of episodes of second-degree atrioventricular block compared to those given acepromazine, and mostly these were in the 30 minutes after premedication, which suggests medetomidine may be the cause. The medetomidine group also had a significantly greater number of dogs with sinus pauses greater than 2 seconds and the median duration of the longest were also significantly longer. It is also important to recognise that the methods that the study used to calculate heartbeat variability values can be affected by unstable experimental conditions, which would have unavoidably happened in this study as the patients were left unattended, especially overnight. Overall, the study does provide data on the cardiac electrical activity and autonomic modulation in dogs undergoing routine surgery when acepromazine or medetomidine is used as part of a premedication, and showed that greater influences on cardiac efferent vagal activities were documented for dogs premedicated with medetomidine than with acepromazine. The clinical importance of this is currently unknown, and further research on this relevance should be conducted.
In the fourth study evaluated (Wamaitha et al., 2019), at four of the five time points when postoperative pain was assessed by pain scoring, the dogs given acepromazine had statistically significantly higher pain scores than those given medetomidine. Again, acepromazine has no analgesic effects (Thurmon et al., 1996; and Smith et al., 2001) which could explain these differences. It may also be important to consider the pain score cut off that studies use for rescue analgesia, as in this study the dogs were given additional analgesia if the pain score was greater than or equal to 13/24, whereas in clinical practice a much lower cut off may be used. The short-form Glasgow Composite Measure Pain Scale (CMPS-SF) is commonly used to pain score animals in clinical practice, as it is a shortened version of the highly validated Glasgow Composite Measure Pain Scale. The clinical intervention point for additional analgesia is 6/24 in the CMPS-SF (Reid et al., 2007), so is considerably lower than the cut off used in this study. This suggests that many more of the dogs in the study may have required additional analgesia if the CMPS-SF cut off value was used to pain score the dogs, and raises potential welfare concerns. The paper also does not report the distribution of the pain score data and presents the median as decimals when the score is an integer. The study reports that the dogs given medetomidine had a smoother recovery based on the finding that dogs given medetomidine took significantly less time to stand, appeared to struggle less and exhibited less tremors on recovery. However, the extubation time was significantly longer than those given acepromazine along with fewer attempts to stand, plus the pedal and palpebral reflexes were absent for longer than those given acepromazine. It is not clear whether the investigator conducting the observations/pain scores was consistent throughout, or whether there were multiple observers as this could lead to inconsistent assessment of the dogs, plus some of the outcomes such as 'appearing to struggle less' are subjective measures.
A key limitation of this study was the sample size; by using only 12dogs split into the two groups, it may not be representative of the normal dog population. It was also not stated by the researchers if any statistical power calculations were carried out in order to work out an adequate sample size to use. Therefore, this may have affected the reliability of the conclusions based on the statistical significance values suggested by the researchers. The researchers also did not analyse any variations in age or weight of the dogs between those allocated to the two different groups and this could have led to individual differences in the dogs confounding the outcome results.
Another limitation of the study is that no evaluation of cardiorespiratory parameters especially perioperatively such as blood pressure, heart rate etc. was performed. These are important measures of potential anaesthetic complications and should have been monitored as part of routine anaesthetic monitoring by the researchers so could have been stated and analysed in the study.
The use of ketofol (ketamine mixed with propofol) is not commonly used in the UK veterinary industry as an induction agent in dogs in combination with propofol, however the use of ketamine in combination induction protocols is routinely used. This induction using ketamine could explain the incidence of muscle tremors during recovery, as ketamine is known to cause muscle tremors, increased muscle tone and spontaneous movement in dogs (Kovalcuka et al., 2013). Alfaxalone is also commonly used as an induction agent in the UK and none of the papers found had evaluated this drug in any of their protocols which could be an area of future research. The study suggested that the reason that the dogs receiving acepromazine exhibited more muscle tremors than those given medetomidine was due to the medetomidine causing muscle relaxation, whereas the acepromazine is not as effective at counteracting the muscle effects of ketamine. Therefore, as ketamine is not often used by vets as a co-induction agent, muscle tremors are less likely to occur in recovery anyway so the clinical benefits of using medetomidine to reduce these may not be relevant. It is also important to consider that the premedication used involved a single drug (acepromazine or medetomidine), whereas in general veterinary practice in the UK a combination using an opioid agent alongside the sedative agent is often used. This sedative and opioid combination may have potentially led to less side effects, than using the sedative agent alone with a ketofol induction.
All of the studies appraised showed some statistically significant differences between using medetomidine and acepromazine as premedications in the outcomes measured, but as the clinical parameters such as blood pressure still were within acceptable clinical limits, the clinical benefits of these findings remain undetermined. There is also evidence to suggest that patients premedicated with medetomidine have less of a perioperative stress response than those receiving acepromazine, but may have increased risk of cardiac conduction disturbances, but the clinical importance of these findings is also unknown. The overall findings showed that either drug can be used as a suitable premedication. However, the differences in pain score postoperatively shown in the small Wamaitha et al. study (2019) and due to its poor analgesic properties, it is suggested that when using acepromazine additional analgesia should be given to reduce postoperative pain for better animal welfare. Another key point to consider is that human error is the most common causes of problems during anaesthetic monitoring (Egger, 2016), therefore being vigilant when monitoring through the anaesthetic period is of paramount importance. To reduce complications, irrespective of the drugs used to premedicate dogs, the patient should be adequately stabilised before beginning procedures and attentive perioperative and postoperative monitoring is vital. It is also important to consider the patients as individuals and adapt anaesthetic protocols to their individual status, to avoid inaccurate drug doses, and to have protocols in place for when complications do arise.
Methodology Section
Databases searched and dates covered: CAB Abstract 1973 – 23rd April 2020
PubMed (NCBI) 1973 – 2020
Web of Science 1900 – 2020
Search strategy: This search strategy was used in all databases:
(elective OR routine OR anesthetized OR anaesthetized OR anesthetized OR anaesthetised OR anaesthesia OR anesthesia OR anaesthetic OR anesthetic OR pre-medication OR premedication OR pre-anaesthetic OR pre-anesthetic OR preanaesthetic OR preanesthetic) and (dog OR dogs OR bitch* OR canine OR canines) AND (acp OR acepromazine and medetomidine)
Dates searches performed: 23 Apr 2020
Exclusion / Inclusion Criteria
Exclusion: Articles not available in English, unsuitable paper types including book chapters, single case reports conference proceedings, irrelevant to the PICO question, inaccessible articles.
Inclusion: Any relevant research relating to the PICO question.
Search Outcome
Excluded – [not available in English language]
Excluded – [case report/book chapter/irrelevant paper type]
Excluded – [irrelevant to PICO question]
Excluded – [duplicate article]
Total relevant papers
119 7 1 106 1 4
Total relevant papers when duplicates removed
The author declares no conflicts of interest.
Abouleish, A.E., Leib, M.L. and Cohen, N.H. (2015). ASA Provides Examples to Each ASA Physical Status Class. ASA Newsletter. 79, 38–49.
Dahl, J.B. and Møiniche S. (2005). Pre-emptive analgesia. British Medical Bulletin. 71(1), 13–27. DOI: https://doi.org/10.1093/bmb/ldh030
Desborough, J.P. (2000). The stress response to trauma and surgery. British Journal of Anaesthesia. 85, 109–117. DOI: https://doi.org/10.1093/bja/85.1.109
Egger, C.M. (2016). BSAVA manual of canine and feline anaesthesia and analgesia. British Small Animal Veterinary Association (BSAVA Manuals Series).
Grimm, K.A., Tranquilli, W.J., Thurmon, J.C. and Benson, G.J. (2000). Duration of nonresponse to noxious stimulation after intramuscular administration of butorphanol, medetomidine, or a butorphanol-medetomidine combination during isoflurane administration in dogs. American Journal of Veterinary Research. 61(1), 42–7. DOI: https://doi.org/10.2460/ajvr.2000.61.42
Grint, N.J., Alderson, B. and Dugdale, A.H. (2010). A comparison of acepromazine-buprenorphine and medetomidine-buprenorphine for preanesthetic medication of dogs. Journal of the American Veterinary Medical Association. 237(12), 1431–7. DOI: http://dx.doi.org/10.2460/javma.237.12.1431
Grood, P.M.R.M.D., Coenen, L.G.J., Egmond, J.V., Booij, L.H.D.J. and Crul, J.F. (1987). Propofol emulsion for induction and maintenance of anaesthesia. A combined technique of general and regional anaesthesia. Acta Anaesthesiologica Scandinavica, 31(3), 219–223. DOI: http://dx.doi.org/10.1111/j.1399-6576.1987.tb02554.x
Kashou, A.H., Goyal, A., Nguyen, T. and Chhabra, L. (2020). Atrioventricular Block. StatPearls Publishing.
Kovalcuka, L., Birgele, E., Bandere, D. and Williams, D.L. (2013). The effects of ketamine hydrochloride and diazepam on the intraocular pressure and pupil diameter of the dog's eye. Veterinary Ophthalmology. 16(1), 29–34. DOI: https://doi.org/10.1111/j.1463-5224.2012.01015.x
Laing, S., Paul, V. and Murison, P.J. (2009). The effects of nitrous oxide on recovery from isoflurane anaesthesia in dogs. Journal of Small Animal Practice. 50(2), 82–86. DOI: https://doi.org/10.1111/j.1748-5827.2008.00689.x
Lerche, P., Reid, J. and Nolan, AM. (2000). Comparative study of propofol or propofol and ketamine for the induction of anaesthesia in dogs. Veterinary Record. 146, 571–574. DOI: http://dx.doi.org/10.1136/vr.146.20.571
Lynch, C. (1986). Differential depression of myocardial contractility by halothane and isoflurane in vitro. Anesthesiology. 64, 620–631. DOI: http://dx.doi.org/10.1097/00000542-198605000-00013
Murrell, J.C. (2016). BSAVA manual of canine and feline anaesthesia and analgesia. British Small Animal Veterinary Association (BSAVA Manuals Series).
Redondo, J.I., Rubio, M., Soler, G., Serra, I., Soler, C. and Gómez‐Villamandos, R.J. (2007). Normal Values and Incidence of Cardiorespiratory Complications in Dogs During General Anaesthesia. A Review of 1281 Cases. Journal of Veterinary Medicine Series A. 54(9), 470–477. DOI: https://doi.org/10.1111/j.1439-0442.2007.00987.x
Reid, J., Nolan, A., Hughes, J., Lascelles, D., Pawson, P. and Scott, E. (2007). Development of the short-form Glasgow Composite Measure Pain Scale (CMPS-SF) and derivation of an analgesic intervention score. Animal Welfare. 16, 97–104.
Smith, L.J., Yu, J.K., Bjorling, D.E. and Waller, K. (2001). Effects of hydromorphone or oxymorphone, with or without acepromazine, on preanesthetic sedation, physiologic values, and histamine release in dogs. Journal of the American Veterinary Medical Association. 218, 1101–1105. DOI: https://doi.org/10.2460/javma.2001.218.1101
Thurmon, J.C., Tranquilli, W.J. and Benson, G.J. (1996). Preanesthetics and anesthetics adjuncts. Veterinary Anesthesia (3rd ed.). Thurmon JC, Tranquilli WJ, Benson GJ (eds). Williams & Wilkins, Baltimore, USA, pp. 183–189.
Tsai, T.Y., Chang, S.K., Chon, P.Y., Yeh, L.S. (2013). Comparison of postoperative effects between lidocaine infusion, meloxicam and their combination in dogs undergoing ovariohysterectomy. Veterinary Anaesthesia Analgesia. 40, 615–22. DOI: https://doi.org/10.1111/vaa.12064
Väisänen, M., Raekallio, M., Kuusela, E., Huttunen, P., Leppäluoto, J., Kirves P. and Vainio, O. (2002). Evaluation of the perioperative stress response in dogs administered medetomidine or acepromazine as part of the preanesthetic medication. American Journal of Veterinary Research. 63(7), 969–975. DOI: https://doi.org/10.2460/ajvr.2002.63.969
Väisänen, M., Vainio, O., Raekallio, M., Hietanen, H., and Huikuri, H. (2005). Results of 24-hour ambulatory electrocardiography in dogs undergoing ovariohysterectomy following premedication with medetomidine or acepromazine. Journal of the American Veterinary Medical Association. 226(5), 738–745. DOI: https://doi.org/10.2460/javma.2005.226.738
Wamaitha, M.N., Mogoa, E.M. and Mande, J.D. (2019). Evaluation of anesthesia produced by ketofol in acepromazine- or medetomidine-sedated dogs. Journal of advanced veterinary and animal research. 6(2), 215–221. DOI: http://doi.org/10.5455/javar.2019.f335
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redpajama_set_name: RedPajamaCommonCrawl


text:
Toyah Wilcox And Band: Punk Princess + '80s Icon
Totally Toyah
Toyah Wilcox is one of a kind. A gifted performer who has conquered music, stage, tv and film, she has an inextinguishable flame and is an inexhaustible performer. In her music career she amasses 13 top 40 singles, recorded 24 albums and toured across the world. She hasn't lost an iota of energy. Expect an electric performance with a full electric band. She'll work her way through classic and new singles, working the crowd the way only someone with her experience can. Don't pass up on this chance to see a living legend at the legendary Boisdale Of Canary Wharf. Choose from a ticket covering dinner and the show, or a ticket including a cocktail and the show. Have a look at the sample menu options below: First Course - Soup of the day - Mini roast Macsween haggis, mash - Dill marinated Scottish salmon with sweet mustard dressing - Salad of chilli and honey roasted sweet potato with crispy shallots, parmesan, rocket (v) Main Course - Sausage of the day, mash with red wine sauce - Deep fried fish cakes, spinach with poached hen's egg, Hollandaise sauce - Pappardelle with Kentish broad beans, peas, pecorino with white wine, olive oil, pea tops (v) - 7oz Fillet steak, Aberdeenshire 30 day dry aged with thick cut chips and béarnaise sauce And here's the cocktails: - Apple Grass: Zubrowka Bison Grass Vodka shaken with honey syrup, fresh lime juice, apple juice and egg white - Orange Blossom: Beefeater Gin, Fee Brothers orange bitters, lime juice, orgeat syrup and pink grapefruit juice shaken and served over ice - Blood and Sand: Glenfiddich 15yr, Gancia Rosso, Heering Cherry and orange juice, shaken and strained into a martini glass - The Governor: Black Grouse mixed with Campari, Aperol and Antica Formula, stirred and served over ice Over 18s only. Guests may wish to dance in front of the stage (or at their tables) and may restrict the view in all areas. Please note the ticket price is per person and includes either a 2 course dinner or a cocktail.
Learn to teach English abroad, remotely or both, from just £19
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Up to 50% off tickets to Urban Missions Bomb Disposal on the streets of London!
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Chaps & Dames, Highbury
51% off bottomless dim sum and a glass of bubbly at Leong's Legend
Leong's Legend, Chinatown


text:
Q: Zend_Cache_Core showing when I am trying to create cache file in view file I am trying to cache a view file content and I am using the following method inside a view file,
$frontendOptions = array(
    'lifetime' => 3600,
    'automatic_serialization' => false
);

$backendOptions = array(
    'cache_dir' => '../cache'
);

$cache = Zend_Cache::factory(
    'Core',
    'File',
    $frontendOptions,
    $backendOptions
);

$cache->save('somebody', 'fileName', array('tag1', tag2));

it is not creating cache file and it is showing the error, the same is working fine in controller.
Any help will be appreciated.
Thanks,
Suresh

A: Replace
$cache->save('somebody', 'fileName', array('tag1', tag2));

by
$cache->save('somebody', 'fileName', array('tag1', 'tag2'));

and
'cache_dir' => '../cache'

by
'cache_dir' => APPLICATION_PATH . '/../caches'

with the cache directory at the same level as the application directory

A: K. V. Suresh you have to send the the Cache Object created by $cache->load(key) to your view's controller in order to access it there.
From your controller:
$data = $cache->load('somebody');
$this->view->cached_data = $data;

From view:
Zend_Debug::dump($this->cache_data);

redpajama_set_name: RedPajamaStackExchange


Ultrasound uses high-frequency sound waves through vibration to transmit thermal effects through the body's tissues. To avoid the risk of burns to the underlying tissue, the treatment head is kept in motion throughout the treatment. According to Dr. Turchin, M.A., D.C., because ultrasound is a form of heat therapy, it does not regenerate tissue or block pain like a cold laser can. It can soften tight connective tissues, but does not promote healing. Ultrasound units are designed to temporarily block pain and reduce inflammation. According to a study found here, laser treatment is more effective than ultrasound on wound healing.
Cold laser (low level laser) is a non-invasive treatment which uses a non-thermal infrared light to reduce inflammation, increase joint mobility, stimulate healing and decrease both short and long term pain. Cold laser is used extensively for injury, pain management and musculoskeletal problems. Another study found here, concluded that low-level laser therapy has shown significant results in reduction of pain and improving function in subjects with chronic plantar fasciitis and is more effective than ultrasound therapy with exercises on chronic plantar fasciitis.
Cold laser therapy stimulates the cells that repair tissues, reduces inflammation and pain. In our free eBook, Dr. Turchin explains that cells that lack energy are unable to participate in the healing process until enough ATP has been produced. Low level laser therapy stimulates the mitochondria of the cell, the cell engine, to produce ATP at higher rates. This stimulates the damaged muscles, ligaments, nerves, bones, joints and soft tissue to re-grow and heal injured cells and tissues.
One of the biggest differences between cold laser and ultrasound therapy is that ultrasound creates heat and cold laser does not. Because of this, ultrasound has more limits and contradictions of how it can be used. Cold laser (low level laser) therapy is fast, painless and more effective for long-term results on injuries and conditions than ultrasound.
• "What are the benefits of Laser Therapy?" eBook by Dr, Turchin, M.A., D.C.


Our goal is to provide alternative care that will reverse and prevent disease using the fundamental healing principles of mind-body rejuvenation. Our results prove the best way to heal the natural body is naturally without pharmaceuticals.
Welcome to Essential Roots Wellness! We are an integrative wellness center offering a variety of complementary modalities to your traditional western medical regimen. Please feel free to ask about any of our services.
We specialize in non-narcotic practices in healing pain such as headaches, chronic pain, joint pain, and back pain. Reiki is a non-invasive technique based on channeling energy to restore physical and emotional well being.
Reflexology sessions help to locate the root of your health issues and reverse them naturally. Reflexology is a non-invasive modality that can treat many chronic and acute diseases, rather than managing or suppressing them. Based on a system of zones and reflex areas, Reflexology provides a deeper healing of mental, emotional, and physical wellness.
A. Expect to be extremely relaxed and open to the endless possibilities. Wear loose comfortable clothing.
Please alert the practitioner to any allergies (aromatherapy) or music/no music preference prior to your session.
Q. Do I have to undress?
A. You will never be asked to undress. Our techniques are applied while you are fully clothed except for Reflexology…where you will be asked to remove your shoes and socks.
Q. What if I do not like to be touched?
A. Reiki techniques can be administered without any touching or with a "light" touch. Reflexology is a specific hands-on technique and will require touching of the feet and/or hands only.
Q. Do I have to come to you or can you come to me?
A. It is preferable that sessions take place in our office, but we understand there can be mobility restrictions in some cases. In this instance, we can accommodate you in your home within a 25 mile radius and a small additional fee of $30 per session to cover travel expenses.
A. There is no physical pain involved with any of our treatments.
A. At this time we accept cash or local checks only.
Q. Do you accept/file insurance?
A. At this time we do not accept insurance. You may check with your FSA or HSA to see if your company allows this expense to be reimbursed. Please notify our practitioner.
Please note that payment is due at time of treatment unless other arrangements have been made with practitioner.
Reflexologists/Reiki Practitioners do not diagnose, prescribe, treat or cure any medical conditions.


text:
Die  Communauté de communes du Canton de Valmont  ist ein ehemaliger französischer Gemeindeverband mit der Rechtsform einer Communauté de communes im Département Seine-Maritime in der Region Normandie. Sie wurde am 30. Dezember 1999 gegründet und umfasste 22 Gemeinden. Der Verwaltungssitz befand sich im Ort Colleville.

Historische Entwicklung
Mit Wirkung vom 1. Januar 2017 fusionierte der Gemeindeverband mit der Fécamp Caux Littoral Agglomération (vor 2017) und
bildete so die Nachfolgeorganisation Fécamp Caux Littoral Agglomération. Trotz der Namensgleichheit handelt es sich um eine Neugründung mit anderer Rechtspersönlichkeit.
Kurz danach wechselten die Gemeinden Criquetot-le-Mauconduit und Vinnemerville zur Communauté de communes Côte d'Albâtre.

Ehemalige Mitgliedsgemeinden
 Ancretteville-sur-Mer
 Angerville-la-Martel
 Colleville
 Contremoulins
 Criquetot-le-Mauconduit
 Écretteville-sur-Mer
 Életot
 Gerponville
 Limpiville
 Riville
 Sainte-Hélène-Bondeville
 Saint-Pierre-en-Port
 Sassetot-le-Mauconduit
 Sorquainville
 Thérouldeville
 Theuville-aux-Maillots
 Thiergeville
 Thiétreville
 Toussaint
 Valmont
 Vinnemerville
 Ypreville-Biville

Canton de Valmont
Gegründet 1999
Aufgelöst 2016

redpajama_set_name: RedPajamaWikipedia


text:
Postpartum Depression: Risk Factors and Treatment Options
By Riyi Shi, MD, PhD
Lori L. Altshuler, MD
Psychiatric TimesPsychiatric Times Vol 21 No 11
The postpartum period represents a time of increased vulnerability for women, though postpartum disorders are often under-recognized and undertreated.
Lifetime prevalence rates of major depressive disorder (MDD) in women are estimated to be as high as 21% (Kessler et al., 1993; Weissman et al., 1993). The postpartum period in particular represents a time of increased vulnerability for women (Cox et al., 1993; O'Hara et al., 1990), though postpartum disorders are often under-recognized and undertreated. Pregnant women generally receive little education about the possibility of depression after delivery, and because symptoms of depression can overlap with common postpartum symptoms, they may go unrecognized. Women may also feel ashamed of having negative emotions at a time when they "should be joyful" and thus not seek professional help.
The DSM-IV defines postpartum depression as a major depressive episode with an onset in the first four weeks following childbirth. Although epidemiologic studies vary in the time frame used to define the postpartum period, ranging from four weeks to six months after delivery, the period of increased risk seems to occur relatively close to delivery. A study by Cox et al. (1993) of 232 postpartum women found that rates of depression were threefold higher in the five weeks after giving birth, but comparable at six months postpartum, when compared to a similarly matched control group of women who had not had a baby within the last 12 months. Wisner et al. (2004a) found that in 51 nondepressed women with a history of postpartum depression, 21 women developed a recurrent postpartum episode when followed for the year after childbirth. Five (24%) of these women experienced depression in the first postpartum month.
Postpartum depression should be distinguished from postpartum blues (commonly known as the baby blues), a relatively common condition that can affect 50% to 80% of women and is characterized by emotional lability, irritability, anxiety and sleep disturbance that usually resolves within two postnatal weeks. Treatment for postpartum blues includes reassurance and validation of the woman's experience, as well as assistance in caring for herself, the home and the baby. However, follow-up of women with postpartum blues is important, as up to 20% go on to develop postpartum depression (Stowe, 1996).
Postpartum depression is the most common psychiatric disorder that occurs in the puerperium, and it affects approximately 10% to 15% of women. Women without a history of major depression have a 10% risk of developing postpartum depression, though the risk of depressive symptomatology may be higher (O'Hara et al., 1990). With a history of major depression, the risk for postpartum depression rises to 25%, and with a history of a prior postpartum depression, the risk of recurrence rises further to 50% (Garvey et al., 1983; O'Hara, 1995). In addition to prior history of depression or postpartum depression, other risk factors for developing a postpartum depression include the following (Beck, 1996; Gotlib et al., 1991; Marks et al., 1992; O'Hara, 1986; Zelkowitz and Milet, 1996):
depressive symptoms during pregnancy
family history of depression
marital difficulties
ambivalence about the pregnancy
limited social support and stressful life events.
Symptoms of postpartum depression are consistent with those of major depression that occurs at any other time in a woman's life, though women suffering from postpartum depression often have marked anxiety (Hendrick et al., 2000) and a tendency to ruminate or even obsess over the health and well-being of the baby. Other features associated with postpartum depression include lower incidence of suicidality (Pitt, 1968) and more difficult social adjustment (O'Hara et al., 1990), when compared to MDD. Although symptoms of postpartum depression can be quite distressing, they are often missed due to preoccupation with the baby or because the symptoms are attributed to the natural stress of caring for a newborn. Since sleep disturbances, appetite and weight changes, and fatigue are common to the postpartum period, the Edinburgh Postnatal Depression Scale (EPDS) (Cox et al., 1987), which focuses on nonsomatic symptoms, is a useful screening instrument for postpartum depression. A thorough evaluation is also important, as failure to address even subsyndromal symptoms can result in progression to a major depressive episode and/or cause impairment in psychosocial functioning and interactions with the infant.
Hormonal Factors
Dramatic hormonal changes occur during pregnancy and shortly after childbirth, and a number of studies have investigated the contribution of reproductive events to the occurrence of postpartum mood disorders. Estrogens, progesterone, β-endorphin, human chorionic gonadotropin, prolactin and cortisol levels rise during pregnancy, reaching maximum levels near term and declining sharply after birth. To date, studies of these biologic factors have not identified a specific etiologic link between reproductive changes and postpartum mood disorders (Hendrick et al., 1998). Nevertheless, women who develop postpartum depression may be especially sensitive to these reproductive changes. Oxytocin, which rises sharply at delivery to stimulate uterine muscle contraction and promote the release of breast milk, has not been studied in relationship to postpartum depression.
Abnormalities in postpartum thyroid function have also been postulated as contributing to postpartum mood disturbance. Rates of postpartum hypothyroidism are relatively high in the first six months after childbirth, with the rate of thyroiditis reaching 9%, compared to 3% to 4% in the general population (Goldman, 1986). While thyroid dysfunction does not seem to account for most cases of postpartum depression, it may play a role for a subgroup of women. In a prospective study of 303 pregnant euthyroid women, postpartum thyroid dysfunction developed in 21 women (7%) (Pop et al., 1991). Of these 21 women, 38% had postpartum depression that resolved with treatment of the thyroid abnormality. Thus, thyroid dysfunction should be considered in the evaluation of a woman who presents with postpartum depression.
Untreated Depression
Untreated postpartum depression may impact maternal functioning, mother-infant bonding and family functioning. Mothers who are depressed are at risk for compromised emotional responsivity to their babies, though maternal behavior varies and maternal depression may not have a singular effect on the infant (Weinberg and Tronick, 1998). Some mothers with depression are disengaged and withdrawn when interacting with their infants, while others can be intrusive, displaying anger and interference. Other mothers are able to mobilize themselves sufficiently to interact positively with their infants (Cohn and Tronick, 1989; Weinberg and Tronick, 1998). Maternal behavior may be influenced by variables such as severity of depression and infant temperament. Nevertheless, maternal depression has been associated with adverse effects on infant attachment and behavior (Murray, 1992; Stein et al., 1991) as well as cognitive development (Cogill et al., 1986).
In a review of the literature, Grace et al. (2003) found that the adverse effects of postpartum depression tend to be greater when the depressive episode is severe and prolonged and when it occurs in the context of adversity. They also found that chronic or recurrent maternal depression is more likely to be related to subsequent effects on the child. These findings underscore the importance of early recognition and treatment of postpartum depression.
The treatment of postpartum depression is multifactorial and includes reassurance, suggestions for increased help around the home, psychoeducation, and, in some cases, psychotherapy and/or pharmacologic treatment (Altshuler et al., 2001). Individual psychotherapy can be an essential part of treatment, especially for women with difficulties adjusting to motherhood and/or fears about new responsibilities. Including a woman's partner in at least one or two meetings can be useful for providing information as well as support. For mothers who find themselves feeling isolated, group psychotherapy may also be helpful.
Psychotherapy treatment studies of postpartum depression have demonstrated the efficacy of interpersonal psychotherapy (IPT). A prospective study by O'Hara et al. (2000) of 120 postpartum women with major depression randomly assigned to 12 weeks of IPT versus a waiting list condition control group found that subjects receiving IPT had significantly greater reduction in depressive symptoms and improvement in social adjustment. Thus, IPT may present an alternative form of treatment to pharmacotherapy, especially for women who are nursing.
Pharmacologic treatment studies for postpartum depression are limited and include one double-blind study demonstrating efficacy of fluoxetine (Prozac) or cognitive-behavioral therapy for major or minor depression (Appleby et al., 1997); one open study each for sertraline (Zoloft), venlafaxine (Effexor) and fluvoxamine (Luvox) (Cohen et al., 2001; Stowe et al., 1995; Suri et al., 2001); and one double-blind, placebo-controlled preventive study for sertraline (Wisner et al., 2004b). Approximately 60% of mothers initiate nursing, and most antidepressants are excreted into breast milk. The majority of reports have not described adverse behavioral effects in nursing infants exposed to antidepressants. In a recent analysis of the available data, Weissman et al. (2004) identified 57 studies of maternal plasma, breast milk and/or infant plasma antidepressant levels from nursing mother-infant pairs. They concluded that sertraline, paroxetine (Paxil) and nortriptyline (Aventyl, Pamelor) may be the preferred choices for nursing women. However, the total number of cases reported for any given medication is small, and concern for infant safety must be considered.
The few months after childbirth represent a time when women may be vulnerable to experiencing postpartum depression. Women should be followed during this period, especially if they have a history of depression or depressive symptoms during pregnancy. Treatment should be multifactorial, including consideration of psychosocial as well as pharmacologic options. Adequate recognition and treatment of postpartum depression is essential to the health and well-being of the mother, the infant and the family.
References 1. Altshuler LL, Cohen LS, Moline ML et al. (2001), The Expert Consensus Guideline Series. Treatment of depression in women. Postgrad Med (Spec No):1-107.
2. Appleby L, Warner R, Whitton A, Faragher B (1997), A controlled study of fluoxetine and cognitive-behavioural counselling in the treatment of postnatal depression. BMJ 314(7085):932-936 [see comments].
3. Beck CT (1996), A meta-analysis of predictors of postpartum depression. Nurs Res 45(5):297-303.
4. Cohen LS, Viguera AC, Bouffard SM et al. (2001), Venlafaxine in the treatment of postpartum depression. J Clin Psychiatry 62(8):592-596.
5. Cogill SR, Caplan HL, Alexandra H et al. (1986), Impact of maternal postnatal depression on cognitive development of young children. Br Med J (Clin Res Ed) 292(6529):1165-1167.
6. Cohn JF, Tronick EZ (1989), Specificity of infants' response to mothers' affective behavior. J Am Acad Child Adolesc Psychiatry 28(2):242-248.
7. Cox JL, Holden JM, Sagovsky R (1987), Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 150:782-786 [see comments].
8. Cox JL, Murray D, Chapman G (1993), A controlled study of the onset, duration and prevalence of postnatal depression. Br J Psychiatry 163:27-31.
9. Garvey MJ, Tuason VB, Lumry AE, Hoffmann NG (1983), Occurrence of depression in the postpartum state. J Affect Disord 5(2):97-101.
10. Goldman JM (1986), Postpartum thyroid dysfunction. Arch Intern Med 146(7):1296-1299.
11. Gotlib IH, Whiffen VE, Wallace PM, Mount JH (1991), Prospective investigation of postpartum depression: factors involved in onset and recovery. J Abnorm Psychol 100(2):122-132.
12. Grace SL, Evindar A, Stewart DE (2003), The effect of postpartum depression on child cognitive development and behavior: a review and critical analysis of the literature. Arch Women Ment Health 6(4):263-274.
13. Hendrick V, Altshuler L, Strouse T, Grosser S (2000), Postpartum and nonpostpartum depression: differences in presentation and response to pharmacologic treatment. Depress Anxiety 11(2):66-72.
14. Hendrick V, Altshuler LL, Suri R (1998), Hormonal changes in the postpartum and implications for postpartum depression. Psychosomatics 39(2):93-101.
15. Kessler RC, McGonagle KA, Swartz M et al. (1993), Sex and depression in the National Comorbidity Survey. I: Lifetime prevalence, chronicity and recurrence. J Affect Disord 29(2-3):85-96.
16. Marks MN, Wieck A, Checkley SA, Kumar R (1992), Contribution of psychological and social factors to psychotic and non-psychotic relapse after childbirth in women with previous histories of affective disorder. J Affect Disord 24(4):253-263.
17. Murray L (1992), The impact of postnatal depression on infant development. J Child Psychol Psychiatry 33(3):543-561.
18. O'Hara MW (1986), Social support, life events, and depression during pregnancy and the puerperium. Arch Gen Psychiatry 43(6):569-573.
19. O'Hara MW (1995), Postpartum Depression: Causes and Consequences (Series in Psychopathology). New York: Springer-Verlag.
20. O'Hara MW, Stuart S, Gorman LL, Wenzel A (2000), Efficacy of interpersonal psychotherapy for postpartum depression. Arch Gen Psychiatry 57(11):1039-1045.
21. O'Hara MW, Zekoski EM, Philipps LH, Wright EJ (1990), Controlled prospective study of postpartum mood disorders: comparison of childbearing and nonchildbearing women. J Abnorm Psychol 99(1):3-15.
22. Pitt B (1968), "Atypical" depression following childbirth. Br J Psychiatry 114(516):1325-1335.
23. Pop VJ, de Rooy HA, Vader HL et al. (1991), Postpartum thyroid dysfunction and depression in an unselected population. [Published erratum N Engl J Med 325(5):371.] N Engl J Med 324(25):1815-1816.
24. Stein A, Gath DH, Bucher J et al. (1991), The relationship between post-natal depression and mother-child interaction. Br J Psychiatry 158:46-52.
25. Stowe ZN (1996), Selected topics pertaining to postpartum psychiatric disorders. Currents in Affective Illness 15(5):5-12.
26. Stowe ZN, Casarella J, Landry J, Nemeroff CB (1995), Sertraline in the treatment of women with postpartum major depression. Depression 3:49-55.
27. Suri R, Burt VK, Altshuler LL et al. (2001), Fluvoxamine for postpartum depression. Am J Psychiatry 158(10):1739-1740 [letter].
28. Weinberg MK, Tronick EZ (1998), The impact of maternal psychiatric illness on infant development. J Clin Psychiatry 59(suppl 2):53-61.
29. Weissman AM, Levy BT, Hartz AJ et al. (2004), Pooled analysis of antidepressant levels in lactating mothers, breast milk, and nursing infants. Am J Psychiatry 161(6):1066-1078.
30. Weissman MM, Bland R, Joyce PR et al. (1993), Sex differences in rates of depression: cross-national perspectives. J Affect Disord 29(2-3):77-84.
31. Wisner KL, Perel JM, Peindl KS, Hanusa BH (2004a), Timing of depression recurrence in the first year after birth. J Affect Disord 78(3):249-252.
32. Wisner KL, Perel JM, Peindl KS et al. (2004b), Prevention of postpartum depression: a pilot randomized clinical trial. Am J Psychiatry 161(7):1290-1292.
33. Zelkowitz P, Milet T (1996), Postpartum psychiatric disorders: their relationship to psychological adjustment and marital satisfaction in the spouses. J Abnorm Psychol 105(2):281-285.
The Week in Review: January 23-27
How to Talk to Teenagers About Substance Use
Blue Light Blockers: A Behavior Therapy for Mania
How to Navigate and Treat 'New Year Depression' in Your Patients
Potentially Treatable Metabolic Abnormalities in Patients with Treatment-Resistant Depression


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On December 20, 2019, this is the special boots that was born in 1998 in 1998. Jordan Brand's special boots designed for female players, will usher in the first time in January next year! The delicate shoe, the spotted leather belt, with a rich air jordan 13 design element! Simple visual creation of black and white shoers, complementing bright red Jumpman logo, the middle of the fashioned boots! Determine the registration of WMNS specifications on January 16, 2020, and some male sizes will be covered.
For Lin Zhiying, everyone should be very familiar. Lin Zhiying is a mass male god. Many people like him very much. Because Lin Zhiying is very excellent, Lin Zhiying debuted for 20 years, his influence is also very big, even now He also has a lot of fans. Moreover, these fans also covers all age layers, and there are many already followed him from him. Looking at him, there is a lot of children to look at him, but Lin Zhiying is also This looks, it feels not old. Lin Zhiying took his family to participate in the "mother-in-law and mother" Lin Zhiying has rarely appeared in front of everyone, and rarely rarely trained in the mainland, so the news for him is very small, generally in entertainment news I can see his message. However, Time, Lin Zhiying, also finally opened, and he took his wife and mother to a real show "mother-in-law and mother", which is Lin Zhiying again, "Dad,", once again recorded mango real show, so it is still People are very surprised. This time, Lin Zhiying has a very surprising with his wife and his mother. But the most unexpectedly, his "Tong Yan", even for a long time, there is no to him, but Lin Zhiying is still the same, there is no change, this Can't help but leave the tears of the times. At this time, I also let everyone see his most real life, and the interaction between him and his mother is also very interesting. The feelings between them are also getting better and better, Lin Mom is also a lot of people. . When Lin Zhiying saw the show for the mother, everyone will not think of it. In fact, Lin Mom is 70 years old, because it really can't see it, it is really very young, saying that it is 50 years old! Recently, Lin Mom has also arrived. Lin Zhiying also helped his mother to celebrate the 70th birthday. The photo of the photo of the birthday will expose, from the scene of the scene, in addition to the family, there are many Lin Zhiying's circle Good friends are also attended. As can be seen from the exposure of the big photo, many people come very familiar with people, everyone is very representative, in addition to Shouxing Forest Mom in the middle, Lin Zhiying's good friends standing Next to it. As can be seen from the figure, the well-known artists such as Lin Junjie, Huo Jianhua and Ou Di also participated in the seventy birthday of Lin Mom, and he had to say that Lin Zhiying's friends were big coffee. Lin Zhiying and friends and the photo between Lin Zhiying and his friends was also exposed. First of all, Lin Zhiying and Huo Jianhua took a photo. Everyone should all know that Lin Zhiying and Lin Xin are a male and female friends before, and Huo Jianhua is also a husband of Lin Xin, such a relationship is also Very complicated. But Lin Zhiying and Huo Jianhua are also good friends, so this time they have attracted the hot discussions between netizens, but they have to say that their feelings are really good, and they are now happy, previous various Also don't care. Another is Lin Junjie and Ou Di, Lin Junjie doesn't have to say more! Lin Junjie is a good singer, everyone knows, because every person has heard his song! The same is the same as Ou Di. Ou Di's performance is also very good before "every day". Many people like him very much. He is also very humorous. These people are also very excited with the same box. It can be seen from the picture. This is the photo sent from Lin Junjie. The four men gods are really very eye-catching, and only a few of them are not only high, but And it's not the same, it feels frozen. This time they have a few frames, fans are also very excited, but they are very excited, but their value evaluation is mixed, but their personal opinion, they are very handsome, after all, childhood Men's gods, most of the 90s also look at their show, watching their dramas, listen to this song! What do they think of them with a few frames, what do you want to say? Welcome to leave a message below!
Zhang Yunlei once is the popularity of De Yun Society second only to Yue Yunpeng's comic actor. Zhang Yunlei is Guo Degang's "Audi", from the small follow-up of Guo Degang, coupled with a layer of relatives between the two, so Zhang Yunlei has been paying attention to the De Yunshi, plus his handsome face, once is Deyun Society "The value of the value", deeply loved the favorite female fans, once a "exploration of the water", let Zhang Yunlei's popularity all the way, in the position of "Demun Yido", unfortunately, Zhang Yunlei "Run" incident, was criticized by public opinion, let him fall into the edge of "being blocked". Despite Guo Degang, Zhang Yunlei's cross talk is still setbacks. In September this year, after nearly a year, De Yunshi officially announced the box, and many people thought that Zhang Yunlei will take this opportunity, re-on Stage, after all, this is his old bank and the main business. However, the first list of the first-box performance announced by De Yunshi did not Zhang Yunlei, and he is still absent in the next few Demun. Even if it is the most important "Deyun", there is still no figure of Zhang Yunlei. As a teacher, Zhang Yunlei, De Yunshi, has set up his own studio and team, which seems to have confirmed the "transformation" statement. In the case of an interview, Guo Degang once revealed that he has been running the "Star Plan", which will hold one or two apprentices every year, so that it can only be able to create, but usually "round", can not put all The resources are all in one person. In 2020, De Yunshuo's red man is not a Qin Yuxian, after participating in the "Deyun Husbandry Society", Qin Xiaoxian's popularity is rising all the way, and now it is the most popular cross talk actor in Deyun, and Qin Yuxian's value is also Very online, and the head is "rich second generation" aura, his current momentum has exceeded Zhang Yunlei in the same year. Guo Degang is more smooth, and the newcomers who have added this year of Johnson, in just a month, in the personal social account twice "single 拎" Qin Xiaoxian, even Yue Yunpeng has not passed this treatment. Zhang Yunlei, which was "entered into the cold palace", it seems that only the transformation of this channel can be left.
These two days about Wang Yibo's hot search, most of them have a relationship with him, but Yin Zheng also boarded the hot search, not only maintaining his own brother's reputation, but he also got a very good The rankings, fans are proud of him. This Zhuhai Zic motorcycle competition, Yin Zheng's achievements are very good, and the incoming circle will take a prize in two years, so that everyone will see his strength. But in this competition, Wang Yibo took a car, and people feel unfortunate. As for the final interpretation of this accident, only the finals and riders have decisions, others don't have much right to evaluate. Many people have found a question after reading this year Zhuhai Zic, everyone is very friendly to Yin Zheng, but I have a hostility for Wang Yibo. Yin Zheng entered the circle in two years, and Wang Yibo was hit by a circle. After seeing this situation, he would not usually worry about Wang Yibo, because he took a year, there are still many professional games to run, just enter the circle This is very difficult to encounter this situation. Many people don't know if those in the motorcycle circle don't like Wang Yibo, but after this Zhuhai Zic game, only the situation inside, only because he made a taboo. Wang Yibo originally an idol. Since he joined the Yama ja team, all the focus of the motorcycle circle was concentrated on him. Others were a little eclipse, and even in the game, the audience only saw Wang Yibo, which is more conspicuous. The rider, in the motorcycle circle is very hateful. The most important thing is that Wang Yibo's team gives him a one-class master. Whether it is a coach, it is a top-level, after seeing such a lineup, some riders are not convinced. After all, Wang Yibang came to this circle soon, there is not much understanding of other teams, just give the top spoilers and coaches, so that many old rides in the motorcycle are backlitted. Everything is only because Wang Yibo is too hot, whether it is in the entertainment industry or a motorcycle ring, his status is very high, which makes a lot of people in this circle can't catch their inner anger, so there is this like this. Best. However, if the barrel is involved, everyone does not know, the official gives the midjust, this competition, Wang Yibo is an accident, and the team has also accepted this result. And Wang Yibo's age is very small, and you can take a long time on this road of motorcycle racing. For this regret, Wang Yibo can only make up for the next game. Anyway, this thing has already happened, can only be contemplated, the motorcycle circle is originally a more exclusive collective, and many people are very exclusive for this airborne motorcycle hand. Many people are very excluded. It is like this is that the other people in the street dance is not very impressive to Wang Yibo. After seeing him dance, he knows that he is a true thing, not a vase. This is also the same in the motorcycle racing. I just started to see Wang Yibo's good, so I didn't accept it, but when he truly ran some achievements in the motorcycle circle, I believe it will let the motorcycle circle. Old rider admire him.
The recent popular TV drama Jinzhi Ye Ye gave Nie Yuan and Wu Jiyan once again received a wave of popularity, Nie Yuan and Wu Jialong said that many good works in recent time, happiness will come to knock on the door, hey, The lanthanum, etc., is a couple, so make a lot of netizens have a question of Nie Yuan and Wu jiguo? Nie Yuan and Wu Jiyan, what is the relationship between Nie Yuan and Wu, is just a relationship between cooperation. The two are actually a positive friend, and the two cooperates so many TV series no matter whether it is a modern drama, or the costume director is So the acting of the two people is very optimistic, so they will think of the two, and the two have not let it disappointed, and the role played is very worried. Nie Yuan and Wu Jindan's TV series, especially in the ourselves and Yanbi Raiders, the two actors are really nice, and they are very couples, although the two ages have a lot of age, but they are very cp, However, although the two are very loving in the play, the two people in reality have not so much love, the two are just a friend, Nie Yuan looks like Wu Jiyan just like a nature. When Nie Yuan Daxhong, Wu Mei said that it is still a student. The stunning of the acting will be much higher than Wu Jiyan, so when Nie Yuan often professor Wu Jie said, there will be so many intimate photos, and Nie Yuan is early Already married, the wife is also in the circle, the color and the acting are not lost to Wu Jindan, just because the entertainment circle is faded after marriage with Nie Yuan, so it will be obscured. What is the relationship between Nie Yuan and Wu? Xiaobian feels relatively pleasing, the character of the two is actually very similar, and it is a friend, and the two are also known for it, although it is different in the circle, but It is really very important to see people 's eyes, and his optimistic actors are really active.
Recently, G-Shock has launched a NASA theme DW-5600 non-watch watch DW5600NASA20-7CR. This watch is a full-white face showing the inspiration from space suit. The details include the NASA pattern on the light gray dial and the American flag and the National Aeronautics and Space Administration all configuration, in order to call the theme, packaging Metal box is rendered by a moon surface trace style, and the carton can see the earth's picture of the space perspective. It is reported that this NASA theme G-Shock DW5600NASA20-7CR watch has been placed.
361 ° and Tencent QQ Speed ??cooperation to create a joint series of shoes, with the spirit of the spirit of the racing e-sports spirit, interpret the theme of "winning unlimited speed". The cooperation of 361 ° and QQ speed will be strong, and through running shoes and racing inspirational sparks perfectly interpret the enthusiasm of never-speed speed, we will launch three joint products, including Lingji - Ruoda Retroceca, Running running shoes and electric - champion running shoes. Lingjun - the design inspiration of the volleyball is from the body form of the A-level racing in the QQ Speed ??Game, and its streamlined shoe is very speed. The upper use of multi-process detail processing, track guidance and fire sprint graphics and multi-level sports lines reflect QQ speed joint elements, while making products more cost-effective while bringing virtual and play to consumers. . Its full-new trend is equipped with NFO technology to fully feel the foot feeling of 42 ° soft bombs, while providing shock absorption performance, the design of the medium waist semi-transmissive TPU has enabled product stability such as tiger. "Wind and" Electricity-Charging "two models of Bound Technology, the unique design of the newly-colored color, the unique appearance of the newly colored performance is expected. As a 2020 QQ Speed ??Master's official partner, 361 ° also created the S Lego Autumn Racing Limited Champion Gift Box, including limited models equipped with the top racing in the game ---- Mam armor running shoes , Racing style sportswear suit, joint short sleeves and the same racing model. The champion gift box will be sold in the mobile game and for its exclusive custom A-level racing - breaking suit. 361 ° QQ Speed ??League Series S Lego Autumn Limited Champion Gift Box will be on the QQ Speed ??Game on August 21. Lingji - Fire god retro old shoes, winds running shoes and electric - chamless sports shoes have been officially pre-sale in the 361 ° Jingdong flagship store and online stores. 361 ° X QQ Speed ??Lingji - Vunion
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Q: How can I set the same key to toggle the folding of the current block in Visual Studio? I need to set on one single key (F1 specifically) both the collapse and the expand of the current block, in VS Pro 2019.
I thought I did it in the past, but I seem not to find it again anymore.
Simply binding both Edit.CollapseCurrentRegion and Edit.ExpandCurrentRegion doesn't work: one overwrites the other.
Ideally there should be a Edit.ToggleCurrentRegion but I couldn't find it.

A: Edit.ToggleOutliningExpansion

I think this should toggle expansion and collapsing of current region. By default it's Ctrl + M + M
Check out more shortcuts here if needed https://learn.microsoft.com/en-us/visualstudio/ide/default-keyboard-shortcuts-in-visual-studio?view=vs-2019


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George Henry Thomas
United States Army general
George Henry Thomas (July 31, 1816 – March 28, 1870) was a general in the U.S. Army. He was one of the top Union army generals in the Western Theater of the American Civil War.
Thomas was born in Virginia in 1816. He graduated from the United States Military Academy in 1840. He fought in the Mexican-American War in an artillery battery. When the Civil War started, he decided to stay in the Union army instead of fighting for Virginia. He became a Brigadier General. He won a victory at the Battle of Mill Springs in Kentucky in 1861.
In 1862, he became a major general and commanded a corps in the Army of the Cumberland. He fought at the Battle of Stones River and the Battle of Chickamauga. He became commander of the Army of the Cumberland during the Chattanooga Campaign in 1863. He continued commanding the army during the Atlanta Campaign. When William T. Sherman started his March to the Sea, Thomas was left behind to defend Tennessee against John Bell Hood. Thomas defeated Hood at the Battle of Nashville in December 1864.
After the war, Thomas stayed with the U.S. army. He died in 1870 in San Francisco.
This short article about a person from the United States can be made longer. You can help Wikipedia by adding to it.
Retrieved from "https://simple.wikipedia.org/w/index.php?title=George_Henry_Thomas&oldid=5499585"


or THE END OF AUCKLAND'S WORLD?
Yes – you already know about the disastrous Auckland disUnity Scam, but new revelations reveal more of just how bad it's getting.
As a consequence of new rules and regulations recently adopted by the Auckland Council, applicable to all of Auckland, hundreds of thousands of Auckland properties and property owners will be ensnared in the Cultural Impact Assessment [CIA] financial enrichment regime of Auckland part-Maori tribes and sub-tribes.
If you thought the epidemic of purple dots was bad enough, submissions to the Auckland Unitary Plan show that part-Maori tribes and sub-tribes want vast areas added to the schedule of 'Sites of Significance,' including Remuera, Pukekohe and Rakino Island!
No part of Auckland is safe from their money-grabbing hands. Waterways, volcanic cones, mountains and hills – you name it.
"The entire [Auckland] area is of significance to this tribe. For the tribe, this is a single cultural landscape, not a series of occasional 'sites'." [Purple dots].
Just in case you missed that: All of Auckland is to become a site of significance and/or value, if that tribe has its way.
Unless you want to become tenants and serfs on your own property, you have until 5.00pm tomorrow, Tuesday 22 July, to get your counter-submission of concern, angst and displeasure in to the Council.
For more information from the Democracy Action web site, click here.


NYC Liberation Mic: a Celebration of Herstory!
Liberation Mic: a Celebration of Herstory!
Last year Liberation Mic turned up for Women's herstory month, but this year will be even better!
With a lineup full of powerful women artists, we will salute our victories and gear up for continued resistance in the fight for equality and liberation for all across the gender spectrum.
Assata Shakur said "A woman's place is in the struggle." The women fighters of today stand on the shoulders of warriors such as Leila Khaled, Sandra Bland, Frida Kahlo, and so many more.
Every month is a month to honor the culture of resistance and everyday is a fresh start for a revolutionary beginning! Join us for some local talent and community building!