Transfundir salva vidas? Não necessariamente. Transfusão sanguínea é medida tomada em excesso

Coleta de sangue de doador. Foto: MartinD/ Commons Licensed

“Condutas e Tecnologias para Realizar Cirurgias de Grande Porte sem Transfusão de Sangue” é o tema da palestra, no 8º AnestEdu, do Dr. Enis Donizetti Silva, coordenador da Residência Médica em Anestesia e do Serviço de Anestesia da Sociedade Beneficente de Senhoras do Hospital Sírio Libanês

Inscreva-se no simpósio! Ainda dá tempo!

Cirurgias com restrição de transfusão sanguínea deixaram de ser um tabu religioso e passaram a ser uma situação à qual é preciso se adequar. Segundo a Joint Commission Accreditation, metade das transfusões de sangue é desnecessária e causa prejuízos de saúde aos pacientes e financeiros às instituições de saúde. Os autores do estudo publicado pelo The Joint Commission Journal on Quality and Patient Safety afirmam que “O custo e os riscos das transfusões de hemácias, além das evidências de uso excessivo das transfusões, demonstram que aprimorar as práticas de transfusão sanguínea é uma oportunidade chave para os sistemas de saúde melhorarem tanto a qualidade quanto o valor do atendimento ao paciente”.

“Transfundir significa salvar vidas? Não”, afirmou o Dr. Enis Donizetti Silva, coordenador da Residência Médica em Anestesia e do Serviço de Anestesia da Sociedade Beneficente de Senhoras do Hospital Sírio Libanês, em aula sobre assunto, em março de 2015, quando era presidente da Sociedade de Anestesiologia do Estado de São Paulo. Segundo ele, evidências demonstram que medidas restritivas em relação à transfusão de sangue têm resultado mais benéfico ao paciente do que as terapias liberais. E indicar uma transfusão de sangue pode ser o mesmo que indicar um transplante, ou seja, um transplante de sangue. “É um transplante de células. Indicamos transplante a torto e a direito? Não, temos critérios muito bem definidos para indicar um transplante de órgãos como rim, fígado, coração, pulmão, e talvez devêssemos utilizar os mesmos critérios em relação à transfusão”, disse ele durante a aula.

O Dr. Donizetti Silva trará ao 8º AnestEdu a palestra “Condutas e Tecnologias para Realizar Cirurgias de Grande Porte sem Transfusão de Sangue”, no Simpósio de Inovação de Gestão em Anestesiologia: Soluções para a Segurança do Paciente com Resultados para as Organizações de Saúde, em 12 de maio, às 15h10. Inscreva-se aqui!

Transfusão de sangue e desfecho

Para o Dr. Enis Donizetti Silva, pode estar havendo uma carência na educação sobre transfusão sanguínea. Em sua mencionada aula, ele disse: “Quantas horas os programas de residência em anestesia, terapia intensiva, cirurgia, cirurgia do trauma reservam, em seus três, quatro, cinco anos, a temas específicos relacionados ao tema transfusão de sangue? Muito pouco. Se a informação é menor, fico acreditando no passado, acredito sempre que transfundir salva vidas”.

Ele explicou que a transfusão tem sido utilizada na medicina moderna há mais de cem anos, acreditando-se que, em pacientes anêmicos, poderia melhorar os resultados clínicos. Mas essa tese nunca foi plenamente investigada ou provada e pode não ser necessariamente verdade.

Na década de 1980 e durante muito tempo, acreditava-se também que transfundir tinha um efeito benéfico do ponto de vista imunológico, ideia que, contou o Dr. Donizetti Silva, veio da observação dos pacientes de transplante de rim. Segundo ele, geralmente sendo pacientes anêmicos, antes da cirurgia, esses pacientes eram transfundidos com uma até três unidades, e observava-se que esses pacientes tinham uma recidiva menor de perda do enxerto. “A verdade é que o sistema HLA do doador competia com o do receptor, com o rim novo que estava chegando. É como se o sistema imunológico tivesse que trabalhar para o novo sangue e não para o novo rim. Repito: quando fazemos uma transfusão, não estamos fazendo um transplante? É como se fizéssemos um mecanismo, passando dois órgãos com o segundo órgão gerando uma resposta imunológica do receptor muito menor. Então, por muito tempo, acreditamos que valia a pena transfundir porque melhorava a imunologia. Hoje sabemos que não, porque quanto mais transfundo, mais infecção, mais recidiva tumoral, mais metástases.”

O Dr. Donizetti Silva afirma que o desfecho é um dos pontos importantes quando se discute Medicina, portanto, é preciso saber o que vai ocorrer com o paciente daqui a um ano, cinco anos e em diante. E quando pacientes transfundidos são analisados depois de três, cinco, 10 anos, verifica-se a incidência muito maior de complicações associadas à transfusão.

Dados brasileiros sobre transfusão sanguínea (2014)*

  • O número de transfusões é crescente.
  • Não há protocolos específicos.
  • O monitoramento é ineficaz.
  • Não há dados de custo-efetividade.
  • A partir de sete dias na UTI, mais de 50% dos pacientes serão submetidos a uma transfusão.
  • A partir de duas semanas na UTI, quase 90% dos pacientes serão submetidos a uma transfusão.

*Fonte: Risco e Segurança do Paciente (FSP, 2016)

 

Veja também no site da WMC Anestesia: Transfusão de sangue – Estamos indicando transfusão… qual a indicação mesmo?

“Não é mais aceitável que a gente recomende transfundir usando ‘Ah, eu julguei que precisa’. Não: você tem de estar baseado em evidências, não é apenas uma conjectura.”

Dra. Ludhmila Abrahão Hajjar, coordenadora da UTI cirúrgica do InCor e do Icesp, coordenadora das UTIs cardiológica e da Insuficiência Cardíaca do Hospital Sírio-Libanês e professora da Faculdade de Medicina da USP.

3.003 comentários

  1. We are a group of volunteers and starting a new scheme in our community. Your site offered us with valuable info to work on. You have done a formidable job and our whole community will be thankful to you.

  2. Does your blog have a contact page? I’m having a tough
    time locating it but, I’d like to shoot you an e-mail.
    I’ve got some recommendations for your blog you might be interested in hearing.

    Either way, great site and I look forward to seeing it expand over time.

  3. Howdy very cool website!! Guy .. Beautiful .. Superb .. I will bookmark your blog and take the feeds also…I am glad to seek out so many useful info right here within the post, we need work out more techniques on this regard, thank you for sharing.

  4. I’d like to thank you for the efforts you have put in writing this blog.

    I really hope to view the same high-grade blog posts
    by you in the future as well. In truth, your creative writing abilities has inspired me to get my own website now 😉

  5. Hello There. I found your weblog the usage of msn. That is
    a really well written article. I will be sure to bookmark it and return to read more of
    your useful information. Thank you for the post. I will certainly comeback.

  6. you’re in reality a just right webmaster. The web site loading speed is amazing. It sort of feels that you’re doing any distinctive trick. Moreover, The contents are masterpiece. you have done a fantastic job in this topic!

  7. Hello There. I found your blog using msn. This is a very well
    written article. I will be sure to bookmark it and return to read more of your
    useful information. Thanks for the post.
    I’ll certainly comeback.

  8. hey there and thank you for your information – I have definitely picked up anything new from right here. I did however expertise some technical issues using this website, since I experienced to reload the web site a lot of times previous to I could get it to load correctly. I had been wondering if your web host is OK? Not that I am complaining, but slow loading instances times will very frequently affect your placement in google and could damage your quality score if ads and marketing with Adwords. Anyway I am adding this RSS to my email and could look out for much more of your respective exciting content. Make sure you update this again very soon..

  9. Good day I am so thrilled I found your web site, I really found
    you by error, while I was researching on Askjeeve for something else,
    Anyhow I am here now and would just like to say kudos for a marvelous post and
    a all round thrilling blog (I also love the
    theme/design), I don’t have time to read through it all at the minute but I have
    book-marked it and also included your RSS feeds, so when I have time I will
    be back to read much more, Please do keep up the superb work.

  10. You are my inhalation , I possess few blogs and very sporadically run out from to brand.I think this internet site has some very fantastic information for everyone. “The expert at anything was once a beginner.” by Hayes.

  11. Hey there! I know this is kinda off topic but I’d
    figured I’d ask. Would you be interested in trading
    links or maybe guest authoring a blog post or vice-versa?
    My website covers a lot of the same topics as yours and I feel we could greatly benefit from each other.
    If you happen to be interested feel free to shoot me an e-mail.
    I look forward to hearing from you! Fantastic blog by the way!

  12. Attractive component to content. I simply stumbled upon your website
    and in accession capital to say that I get in fact
    loved account your blog posts. Anyway I’ll be subscribing to your feeds
    or even I success you get admission to consistently quickly.

  13. I believe everything posted made a great deal of sense.
    But, consider this, what if you composed a catchier
    post title? I am not suggesting your content
    isn’t good, but what if you added a post title that grabbed people’s attention? I mean Transfundir salva vidas?
    Não necessariamente. Transfusão sanguínea é medida tomada em excesso
    – AnestEdu is a little boring. You might glance at Yahoo’s front page and watch how they create news titles to get people to open the links.
    You might add a related video or a related picture or two to get readers excited
    about everything’ve written. Just my opinion, it would bring your posts a little bit more interesting.

  14. I got what you mean , regards for putting up.Woh I am glad to find this website through google. “Do not be too timid and squeamish about your actions. All life is an experiment.” by Ralph Waldo Emerson.

  15. Thanks for sharing excellent informations. Your web site is very cool. I am impressed by the details that you have on this site. It reveals how nicely you perceive this subject. Bookmarked this website page, will come back for extra articles. You, my pal, ROCK! I found simply the info I already searched all over the place and simply couldn’t come across. What a great web-site.

  16. I was just looking for this information for a while. After six hours of continuous Googleing, finally I got it in your web site. I wonder what’s the lack of Google strategy that do not rank this kind of informative web sites in top of the list. Normally the top web sites are full of garbage.

  17. I¡¦m no longer positive the place you are getting your information, however great topic. I must spend a while studying more or working out more. Thank you for excellent info I was looking for this information for my mission.

  18. I have been surfing online greater than 3 hours today, but I by
    no means found any attention-grabbing article like
    yours. It’s pretty worth enough for me. Personally, if all website owners and bloggers made
    good content material as you did, the internet will likely be
    much more helpful than ever before.

  19. Some really good blog posts on this internet site, thanks for contribution. “Once, power was considered a masculine attribute. In fact, power has no sex.” by Katharine Graham.

  20. I am extremely impressed with your writing skills as well as with the layout on your blog. Is this a paid theme or did you customize it yourself? Anyway keep up the excellent quality writing, it is rare to see a nice blog like this one these days..

  21. You actually make it seem so easy with your presentation but I find this matter to be really something which I think I would never understand. It seems too complex and extremely broad for me. I am looking forward for your next post, I’ll try to get the hang of it!

  22. I am extremely impressed with your writing skills as well as with the layout on your blog. Is this a paid theme or did you customize it yourself? Anyway keep up the excellent quality writing, it’s rare to see a great blog like this one nowadays..

  23. I wanted to write a small note so as to say thanks to you for these amazing concepts you are giving at this website. My extended internet look up has now been compensated with good facts and strategies to exchange with my friends and classmates. I would suppose that many of us website visitors actually are very much fortunate to be in a decent website with many lovely individuals with very beneficial pointers. I feel truly happy to have encountered the web pages and look forward to plenty of more entertaining moments reading here. Thanks a lot once more for a lot of things.

  24. I¡¦ve been exploring for a bit for any high-quality articles or blog posts in this sort of space . Exploring in Yahoo I at last stumbled upon this site. Reading this info So i am glad to exhibit that I’ve an incredibly good uncanny feeling I discovered exactly what I needed. I most indubitably will make certain to do not omit this website and provides it a glance on a continuing basis.

  25. Hi there, just became aware of your blog through Google, and found that it’s really informative. I’m going to watch out for brussels. I will appreciate if you continue this in future. A lot of people will be benefited from your writing. Cheers!

  26. I precisely desired to thank you so much once again. I’m not certain the things that I would’ve sorted out without the actual tactics documented by you concerning that area of interest. It had become a very horrifying crisis for me, but noticing a new specialised technique you handled the issue took me to cry over fulfillment. I am just happier for this guidance as well as expect you really know what an amazing job you happen to be carrying out training men and women all through your web site. I am sure you have never met any of us.

  27. I do trust all of the concepts you have offered in your post. They are really convincing and can definitely work. Nonetheless, the posts are too quick for newbies. Could you please lengthen them a bit from next time? Thanks for the post.

  28. naturally like your website however you need to take a look at the spelling on several of your posts. Many of them are rife with spelling problems and I to find it very bothersome to tell the truth on the other hand I¡¦ll surely come back again.

  29. Hiya very nice site!! Guy .. Beautiful .. Amazing .. I’ll bookmark your website and take the feeds additionally¡KI’m glad to seek out a lot of helpful information right here within the publish, we need work out extra techniques in this regard, thank you for sharing. . . . . .

  30. Simply want to say your article is as amazing. The clearness in your post is simply cool and i can assume you are an expert on this subject. Well with your permission allow me to grab your RSS feed to keep up to date with forthcoming post. Thanks a million and please continue the rewarding work.

  31. I¡¦ve been exploring for a little for any high-quality articles or weblog posts in this sort of house . Exploring in Yahoo I finally stumbled upon this web site. Reading this information So i am happy to convey that I have a very excellent uncanny feeling I came upon just what I needed. I most unquestionably will make certain to do not disregard this site and give it a look on a relentless basis.

  32. First off I would like to say great blog! I had a quick question which I’d like to ask if you do not mind.
    I was interested to find out how you center yourself and clear your head prior to writing.
    I’ve had a tough time clearing my thoughts in getting my thoughts out there.

    I truly do enjoy writing however it just seems like the first 10 to 15
    minutes are usually wasted simply just trying to figure out how to begin. Any suggestions or
    hints? Kudos!

  33. I do not know if it’s just me or if perhaps everyone else experiencing issues with your blog. It appears like some of the text in your posts are running off the screen. Can somebody else please provide feedback and let me know if this is happening to them as well? This could be a problem with my browser because I’ve had this happen before. Kudos

  34. I don’t know whether it’s just me or if perhaps everybody else experiencing issues with your site. It seems like some of the text within your content are running off the screen. Can somebody else please comment and let me know if this is happening to them too? This could be a problem with my browser because I’ve had this happen previously. Kudos

  35. I don’t know if it’s just me or if perhaps everybody else encountering problems with your website. It appears as if some of the written text on your content are running off the screen. Can somebody else please provide feedback and let me know if this is happening to them as well? This may be a problem with my internet browser because I’ve had this happen before. Kudos

  36. you’re really a just right webmaster. The site loading velocity is amazing. It seems that you’re doing any unique trick. Moreover, The contents are masterpiece. you have performed a magnificent process in this topic!

  37. Good site! I really love how it is easy on my eyes and the data are well written. I am wondering how I might be notified whenever a new post has been made. I’ve subscribed to your RSS feed which must do the trick! Have a nice day!

  38. I wanted to put you this tiny note just to give many thanks as before regarding the fantastic guidelines you have shown on this page. This has been quite seriously generous with you to give freely just what most people would have sold as an electronic book in order to make some cash for themselves, primarily considering that you could have done it in case you wanted. Those inspiring ideas as well worked as the great way to realize that most people have a similar dream just as mine to realize a whole lot more related to this matter. I think there are lots of more fun sessions in the future for folks who see your site.

  39. I think this is one of the most important information for me. And i’m glad reading your article. But should remark on some general things, The website style is wonderful, the articles is really excellent : D. Good job, cheers

  40. I do not know if it’s just me or if everyone else encountering issues with your website. It appears as though some of the written text on your content are running off the screen. Can somebody else please comment and let me know if this is happening to them too? This might be a problem with my web browser because I’ve had this happen previously. Thanks

  41. I don’t know if it’s just me or if everybody else experiencing problems with your site. It appears like some of the written text on your content are running off the screen. Can somebody else please comment and let me know if this is happening to them too? This may be a issue with my browser because I’ve had this happen before. Thank you

  42. Great ¡V I should certainly pronounce, impressed with your site. I had no trouble navigating through all the tabs and related info ended up being truly simple to do to access. I recently found what I hoped for before you know it at all. Quite unusual. Is likely to appreciate it for those who add forums or something, website theme . a tones way for your client to communicate. Nice task..

  43. I do agree with all the ideas you have introduced for your post. They’re really convincing and can definitely work. Nonetheless, the posts are very short for newbies. May just you please lengthen them a bit from subsequent time? Thank you for the post.

  44. hello!,I love your writing very a lot! percentage we communicate more approximately your article on AOL? I require a specialist on this house to resolve my problem. Maybe that is you! Looking ahead to see you.

  45. I wanted to compose you the tiny observation to be able to give many thanks again for all the magnificent thoughts you have shared on this page. This has been certainly remarkably open-handed of people like you to supply without restraint all that most people would have offered for sale for an electronic book to help with making some cash on their own, even more so since you could have tried it in case you considered necessary. Those inspiring ideas as well acted as a good way to fully grasp the rest have the identical dream just like my own to figure out significantly more pertaining to this issue. I am sure there are lots of more fun periods up front for many who scan your website.

  46. Thank you for the sensible critique. Me & my neighbor were just preparing to do some research on this. We got a grab a book from our local library but I think I learned more from this post. I’m very glad to see such magnificent info being shared freely out there.

  47. You actually make it seem so easy with your presentation but I find this matter to be really something that I
    think I would never understand. It seems too complex and very broad
    for me. I’m looking forward for your next post, I’ll try to
    get the hang of it!

  48. Thank you for any other great post. Where else could anyone get that kind of information in such a perfect method of writing? I have a presentation subsequent week, and I’m on the search for such info.

  49. You really make it seem so easy with your presentation but I find this topic to be actually something that I think I would never understand. It seems too complicated and very broad for me. I’m looking forward for your next post, I will try to get the hang of it!

  50. Pretty nice post. I just stumbled upon your blog and wished to say that I’ve truly enjoyed browsing your blog posts. After all I’ll be subscribing to your rss feed and I hope you write again very soon!

  51. It is the best time to make some plans for the future and it is time to be happy. I have read this post and if I could I desire to suggest you few interesting things or suggestions. Maybe you could write next articles referring to this article. I want to read more things about it!

  52. I was just looking for this information for some time. After six hours of continuous Googleing, finally I got it in your web site. I wonder what is the lack of Google strategy that don’t rank this type of informative sites in top of the list. Usually the top sites are full of garbage.

  53. Unquestionably believe that which you said. Your favorite justification appeared to be on the web the simplest thing to be aware of. I say to you, I certainly get annoyed while people consider worries that they just do not know about. You managed to hit the nail upon the top and also defined out the whole thing without having side-effects , people can take a signal. Will probably be back to get more. Thanks

  54. Terrific work! That is the type of info that should be shared around the web. Disgrace on the seek engines for now not positioning this put up higher! Come on over and consult with my website . Thank you =)

  55. Good website! I truly love how it is easy on my eyes and the data are well written. I am wondering how I could be notified when a new post has been made. I’ve subscribed to your RSS feed which must do the trick! Have a great day!

  56. Thank you for the sensible critique. Me & my neighbor were just preparing to do some research on this. We got a grab a book from our local library but I think I learned more from this post. I’m very glad to see such magnificent information being shared freely out there.

  57. Hi there, just became alert to your blog through Google, and found that it is truly informative. I’m gonna watch out for brussels. I will appreciate if you continue this in future. Lots of people will be benefited from your writing. Cheers!

  58. What i do not understood is in reality how you’re not actually a lot more smartly-liked than you may be right now. You’re so intelligent. You already know therefore significantly relating to this topic, made me for my part imagine it from so many varied angles. Its like men and women don’t seem to be fascinated except it¡¦s one thing to accomplish with Woman gaga! Your personal stuffs great. Always deal with it up!

  59. What i don’t realize is if truth be told how you’re no longer actually a lot more smartly-favored than you might be now. You are so intelligent. You already know therefore considerably when it comes to this matter, made me in my view consider it from so many numerous angles. Its like women and men don’t seem to be involved until it is something to accomplish with Girl gaga! Your individual stuffs great. At all times care for it up!

  60. You actually make it seem so easy with your presentation but I find this topic to be actually something that I think I would never understand. It seems too complex and very broad for me. I am looking forward for your next post, I will try to get the hang of it!

  61. Hello, i think that i saw you visited my weblog so i came to “return the favor”.I am attempting to find things to improve my site!I suppose its ok to use some of your ideas!!

  62. Thank you, I have just been searching for info approximately this subject for ages and yours is the best I’ve came upon till now. But, what concerning the bottom line? Are you sure concerning the source?

  63. Thank you for any other fantastic post. The place else may anybody get that kind of information in such an ideal means of writing? I’ve a presentation next week, and I am on the look for such information.

  64. Good ¡V I should definitely pronounce, impressed with your web site. I had no trouble navigating through all tabs as well as related information ended up being truly simple to do to access. I recently found what I hoped for before you know it in the least. Quite unusual. Is likely to appreciate it for those who add forums or anything, web site theme . a tones way for your client to communicate. Excellent task..

  65. I’ve recently started a website, the info you provide on this website has helped me tremendously. Thanks for all of your time & work. “A physicist is an atom’s way of knowing about atoms.” by George Wald.

  66. My partner and I stumbled over here from a different web address and thought I might as well check
    things out. I like what I see so now i am following you.
    Look forward to looking over your web page repeatedly.

  67. I am glad for commenting to make you understand what a brilliant experience our child found reading through your webblog. She even learned many issues, not to mention what it’s like to possess a marvelous helping character to get the mediocre ones with ease know precisely selected very confusing things. You actually exceeded my desires. Thank you for coming up with the precious, dependable, revealing and even fun thoughts on the topic to Evelyn.

  68. Attractive section of content. I just stumbled upon your site and in accession capital to assert that I acquire in fact enjoyed account your blog posts. Any way I’ll be subscribing to your feeds and even I achievement you access consistently quickly.

  69. I like this site so much, saved to my bookmarks. “Respect for the fragility and importance of an individual life is still the mark of an educated man.” by Norman Cousins.

  70. Do you mind if I quote a couple of your posts as long as I provide credit and sources back to your site? My blog site is in the very same niche as yours and my users would truly benefit from some of the information you present here. Please let me know if this ok with you. Thanks a lot!

  71. I just like the helpful info you provide on your articles. I will bookmark your weblog and test once more here frequently. I’m somewhat certain I will learn many new stuff proper right here! Good luck for the following!

  72. Hi there, just became alert to your blog through Google, and found that it is truly informative. I am gonna watch out for brussels. I’ll be grateful if you continue this in future. Numerous people will be benefited from your writing. Cheers!

  73. Whats Taking place i am new to this, I stumbled upon this I have discovered It positively useful and it has helped me out loads. I’m hoping to contribute & help different customers like its helped me. Great job.

  74. I like the helpful info you supply for your articles. I will bookmark your weblog and test again here regularly. I am reasonably certain I’ll be told many new stuff proper here! Best of luck for the next!

  75. Do you mind if I quote a few of your articles as long as I provide credit and sources back to your weblog? My blog site is in the very same niche as yours and my users would truly benefit from some of the information you present here. Please let me know if this ok with you. Cheers!

  76. Simply desire to say your article is as astonishing. The clarity in your post is simply cool and i could assume you are an expert on this subject. Well with your permission let me to grab your feed to keep updated with forthcoming post. Thanks a million and please continue the enjoyable work.

  77. Thank you, I have just been searching for information about this subject for ages and yours is the greatest I have came upon so far. However, what in regards to the conclusion? Are you sure concerning the source?

  78. Do you mind if I quote a few of your posts as long as I provide credit and sources back to your site? My blog site is in the exact same niche as yours and my visitors would certainly benefit from some of the information you present here. Please let me know if this alright with you. Cheers!

  79. I just like the valuable information you provide for your articles. I’ll bookmark your weblog and test once more here regularly. I’m quite certain I’ll be told lots of new stuff proper right here! Best of luck for the following!

  80. Do you mind if I quote a few of your posts as long as I provide credit and sources back to your weblog? My website is in the very same area of interest as yours and my visitors would certainly benefit from a lot of the information you provide here. Please let me know if this alright with you. Thanks a lot!

  81. I have been exploring for a little for any high-quality articles or blog posts on this kind of area . Exploring in Yahoo I at last stumbled upon this web site. Reading this information So i¡¦m glad to exhibit that I have an incredibly good uncanny feeling I came upon just what I needed. I so much undoubtedly will make certain to do not put out of your mind this site and provides it a look on a continuing basis.

  82. I like the valuable information you supply on your articles. I’ll bookmark your weblog and take a look at once more right here frequently. I am rather sure I will be told a lot of new stuff proper here! Best of luck for the next!

  83. Thanks for any other informative site. The place else could I am getting that type of info written in such an ideal way? I’ve a mission that I’m just now operating on, and I have been at the glance out for such information.

  84. I like the helpful information you supply on your articles. I’ll bookmark your weblog and take a look at once more right here frequently. I am quite sure I’ll be informed many new stuff proper right here! Best of luck for the next!

  85. I like the valuable info you supply on your articles. I’ll bookmark your blog and take a look at once more right here frequently. I am relatively certain I will be informed many new stuff proper right here! Best of luck for the following!

  86. Do you mind if I quote a couple of your articles as long as I provide credit and sources back to your blog? My website is in the exact same area of interest as yours and my visitors would certainly benefit from a lot of the information you present here. Please let me know if this okay with you. Thanks a lot!

  87. I think this is among the most vital information for me. And i am glad reading your article. But want to remark on few general things, The website style is perfect, the articles is really nice : D. Good job, cheers

  88. I am not certain where you’re getting your information, however great topic. I needs to spend a while learning more or figuring out more. Thanks for wonderful information I was looking for this information for my mission.

  89. I loved as much as you’ll receive carried out right here. The sketch is tasteful, your authored material stylish. nonetheless, you command get bought an nervousness over that you wish be delivering the following. unwell unquestionably come further formerly again as exactly the same nearly very often inside case you shield this increase.

  90. I do consider all the concepts you’ve introduced to your post. They are very convincing and will definitely work. Nonetheless, the posts are too quick for starters. Could you please lengthen them a little from next time? Thanks for the post.

  91. of course like your website however you need to check the spelling on several of your posts. Many of them are rife with spelling issues and I in finding it very bothersome to tell the truth on the other hand I will surely come again again.

  92. you are in reality a excellent webmaster. The website loading velocity is incredible. It sort of feels that you’re doing any distinctive trick. Moreover, The contents are masterpiece. you have done a magnificent process in this subject!

  93. Excellent post. I was checking continuously this blog and I am impressed! Extremely useful information particularly the last part 🙂 I care for such information a lot. I was looking for this particular info for a very long time. Thank you and best of luck.

  94. Its like you read my mind! You appear to know a lot about this, like you wrote the book in it or something. I think that you can do with some pics to drive the message home a little bit, but other than that, this is wonderful blog. A great read. I’ll certainly be back.

  95. I am not certain the place you are getting your information, however great topic. I needs to spend some time finding out much more or working out more. Thanks for excellent info I was in search of this information for my mission.

  96. Do you mind if I quote a few of your articles as long as I provide credit and sources back to your weblog? My blog site is in the exact same area of interest as yours and my visitors would truly benefit from some of the information you provide here. Please let me know if this ok with you. Regards!

  97. certainly like your web site however you have to check the spelling on quite a few of your posts. A number of them are rife with spelling issues and I find it very troublesome to inform the reality nevertheless I will definitely come again again.

  98. Do you mind if I quote a few of your posts as long as I provide credit and sources back to your webpage? My blog site is in the very same niche as yours and my users would really benefit from some of the information you present here. Please let me know if this ok with you. Thank you!

  99. I just like the valuable info you provide to your articles. I will bookmark your blog and test again right here regularly. I am rather sure I’ll be told lots of new stuff proper here! Best of luck for the next!

  100. Do you mind if I quote a few of your posts as long as I provide credit and sources back to your webpage? My website is in the very same niche as yours and my visitors would certainly benefit from a lot of the information you provide here. Please let me know if this alright with you. Regards!

  101. I just like the helpful info you provide to your articles. I will bookmark your blog and test once more here frequently. I am moderately sure I will learn a lot of new stuff right right here! Good luck for the following!

  102. I have not checked in here for a while since I thought it was getting boring, but the last several posts are great quality so I guess I will add you back to my everyday bloglist. You deserve it my friend 🙂

  103. I’ve been surfing on-line greater than three hours nowadays, yet I by no means discovered any fascinating article like yours. It¡¦s beautiful price sufficient for me. In my opinion, if all site owners and bloggers made good content material as you probably did, the web will be much more helpful than ever before.

  104. You could definitely see your expertise within the work you write. The arena hopes for more passionate writers such as you who are not afraid to mention how they believe. At all times go after your heart.

  105. Thank you so much for providing individuals with an extremely pleasant chance to read from this web site. It is often very beneficial and also stuffed with fun for me and my office fellow workers to visit the blog at minimum thrice in 7 days to study the latest stuff you have got. Of course, we’re usually contented concerning the remarkable knowledge served by you. Selected two tips in this post are rather the most suitable I’ve had.

  106. Do you mind if I quote a few of your posts as long as I provide credit and sources back to your webpage? My website is in the very same niche as yours and my visitors would truly benefit from a lot of the information you present here. Please let me know if this ok with you. Thanks a lot!

  107. Undeniably believe that which you said. Your favorite reason seemed to be on the web the easiest thing to be aware of. I say to you, I certainly get annoyed while people think about worries that they just do not know about. You managed to hit the nail upon the top and defined out the whole thing without having side-effects , people could take a signal. Will likely be back to get more. Thanks

  108. I simply could not leave your website before suggesting that I actually loved the usual information a person supply in your visitors? Is gonna be back frequently to check up on new posts

  109. Do you mind if I quote a few of your posts as long as I provide credit and sources back to your webpage? My website is in the very same area of interest as yours and my visitors would genuinely benefit from a lot of the information you provide here. Please let me know if this ok with you. Thanks a lot!

  110. I just like the helpful info you supply to your articles. I’ll bookmark your weblog and take a look at again right here regularly. I am relatively sure I will be informed plenty of new stuff proper here! Good luck for the following!

  111. I just like the helpful information you supply in your articles. I will bookmark your weblog and test once more here regularly. I am fairly sure I’ll be told plenty of new stuff right right here! Best of luck for the next!

  112. hi!,I like your writing so a lot! share we keep up a correspondence extra about your article on AOL? I require a specialist on this area to unravel my problem. May be that’s you! Having a look forward to see you.

  113. I am now not certain the place you’re getting your info, but
    good topic. I must spend a while finding out much more or working out more.
    Thank you for excellent information I used to be looking for this information for my
    mission.

  114. Thanks , I have recently been looking for info approximately this subject for a long time and yours is the greatest I’ve discovered so far. However, what in regards to the conclusion? Are you certain concerning the source?

  115. I think this is among the most important info for me. And i am glad reading your article. But want to remark on few general things, The site style is ideal, the articles is really excellent : D. Good job, cheers

  116. I cling on to listening to the reports lecture about receiving free online grant applications so I have been looking around for the finest site to get one. Could you tell me please, where could i find some?

  117. I think this is among the most vital information for me. And i am glad reading your article. But want to remark on some general things, The web site style is ideal, the articles is really excellent : D. Good job, cheers

  118. I would like to thnkx for the efforts you’ve put in writing this blog. I’m hoping the same high-grade website post from you in the upcoming also. In fact your creative writing abilities has inspired me to get my own blog now. Really the blogging is spreading its wings fast. Your write up is a great example of it.

  119. Hi exceptional website! Does running a blog such as this
    require a great deal of work? I have absolutely no
    expertise in coding but I had been hoping to start my
    own blog in the near future. Anyway, should you
    have any ideas or tips for new blog owners please share.
    I understand this is off subject nevertheless
    I just wanted to ask. Thank you!

  120. hello there and thank you for your information – I have certainly picked up something new from right here. I did however expertise some technical points using this web site, as I experienced to reload the site lots of times previous to I could get it to load correctly. I had been wondering if your web hosting is OK? Not that I’m complaining, but sluggish loading instances times will often affect your placement in google and can damage your quality score if advertising and marketing with Adwords. Anyway I’m adding this RSS to my email and can look out for much more of your respective interesting content. Make sure you update this again very soon..

  121. I¡¦ll right away take hold of your rss as I can not to find your email subscription link or e-newsletter service. Do you’ve any? Kindly allow me recognise in order that I may just subscribe. Thanks.

  122. What i do not understood is actually how you’re now not really a lot more neatly-appreciated than you may be now. You’re very intelligent. You know thus significantly relating to this matter, made me in my opinion imagine it from a lot of various angles. Its like women and men are not involved except it¡¦s one thing to accomplish with Girl gaga! Your personal stuffs great. Always maintain it up!

  123. I just couldn’t go away your website prior to suggesting that I extremely enjoyed the usual information a person supply for your guests? Is going to be again ceaselessly to check out new posts

  124. Do you mind if I quote a few of your articles as long as I provide credit and sources back to your website? My blog is in the exact same niche as yours and my users would really benefit from some of the information you provide here. Please let me know if this okay with you. Cheers!

  125. I’ve been browsing online more than 3 hours today, yet I never found any interesting article like yours. It’s pretty worth enough for me. Personally, if all web owners and bloggers made good content as you did, the web will be much more useful than ever before.

  126. My wife and i felt absolutely happy that Jordan could carry out his survey out of the precious recommendations he obtained using your web page. It is now and again perplexing to just find yourself freely giving points people may have been trying to sell. And we fully grasp we need the blog owner to give thanks to because of that. The explanations you’ve made, the simple web site navigation, the relationships you make it possible to foster – it is most sensational, and it is assisting our son in addition to the family do think this article is thrilling, which is certainly really vital. Thanks for everything!

  127. Great items from you, man. I’ve understand your stuff previous to and you are just extremely
    great. I really like what you’ve acquired here, certainly like what you’re stating and the way through which
    you are saying it. You’re making it enjoyable and you still take care of to keep it wise.

    I can not wait to read far more from you. This
    is actually a terrific site.

  128. I just like the helpful information you provide in your articles. I will bookmark your weblog and check again here frequently. I am reasonably sure I’ll be informed many new stuff right right here! Good luck for the next!

  129. I like the helpful info you supply on your articles. I’ll bookmark your blog and take a look at once more right here frequently. I am reasonably certain I will learn lots of new stuff proper right here! Best of luck for the next!

  130. My spouse and i were really happy when Raymond managed to deal with his investigation through the ideas he had in your site. It’s not at all simplistic to simply always be offering information which usually the others might have been trying to sell. And we all discover we need the website owner to appreciate because of that. These explanations you made, the simple blog navigation, the friendships you make it possible to engender – it’s got all awesome, and it is making our son and our family reckon that the article is interesting, which is certainly wonderfully fundamental. Thank you for the whole lot!

  131. I just like the helpful information you provide to your articles. I’ll bookmark your weblog and test once more here regularly. I am rather certain I will be informed many new stuff right here! Good luck for the following!

  132. I needed to send you the little remark just to thank you very much once again with your extraordinary concepts you’ve shown in this case. This is so shockingly generous of you to allow extensively what most people would’ve marketed as an e book to end up making some cash for themselves, mostly seeing that you could possibly have tried it in case you considered necessary. Those techniques as well worked as a fantastic way to be certain that other people online have the same keenness much like mine to know the truth good deal more in regard to this condition. I am sure there are numerous more fun moments in the future for individuals who browse through your blog.

  133. I just like the valuable information you provide on your articles. I will bookmark your blog and check once more right here regularly. I am relatively certain I’ll learn a lot of new stuff proper here! Best of luck for the next!

  134. I happen to be writing to let you be aware of of the exceptional experience my girl obtained reading through your web page. She noticed lots of things, which included what it’s like to have a great giving mood to have other individuals easily understand specific extremely tough subject matter. You undoubtedly exceeded my expectations. Thank you for delivering the practical, dependable, informative and in addition easy guidance on this topic to Janet.

  135. Definitely imagine that which you said. Your favorite justification seemed to be on the web the simplest
    factor to be mindful of. I say to you, I certainly get irked whilst other folks consider
    issues that they just don’t recognise about. You controlled to hit the nail upon the top and defined out the whole thing with no need side effect , folks could take a
    signal. Will probably be again to get more. Thank you

  136. Do you mind if I quote a few of your posts as long as I provide credit and sources back to your site? My blog site is in the exact same niche as yours and my visitors would really benefit from a lot of the information you present here. Please let me know if this alright with you. Thank you!

  137. Right here is the right web site for anybody who would like to
    understand this topic. You know a whole lot its almost hard to argue
    with you (not that I really will need to…HaHa). You
    definitely put a fresh spin on a topic that has been written about for a long time.
    Excellent stuff, just great!

  138. Do you mind if I quote a couple of your articles as long as I provide credit and sources back to your site? My website is in the exact same niche as yours and my visitors would truly benefit from some of the information you provide here. Please let me know if this okay with you. Appreciate it!

  139. Do you mind if I quote a few of your articles as long as I provide credit and sources back to your weblog? My blog is in the exact same area of interest as yours and my users would definitely benefit from a lot of the information you provide here. Please let me know if this okay with you. Many thanks!

  140. Thank you so much for giving everyone an extremely wonderful chance to check tips from this site. It’s usually very nice plus full of fun for me personally and my office friends to search your web site on the least three times every week to find out the latest secrets you have got. Not to mention, I am always happy concerning the impressive concepts you serve. Some 1 facts on this page are definitely the most beneficial I have had.

  141. You actually make it appear so easy together with your presentation but I find this topic to be actually something that I believe I might never understand. It sort of feels too complex and very broad for me. I’m having a look ahead on your next post, I will try to get the grasp of it!

  142. Do you mind if I quote a few of your articles as long as I provide credit and sources back to your weblog? My website is in the very same niche as yours and my users would genuinely benefit from some of the information you present here. Please let me know if this okay with you. Thank you!

  143. Good ¡V I should definitely pronounce, impressed with your web site. I had no trouble navigating through all tabs as well as related information ended up being truly easy to do to access. I recently found what I hoped for before you know it at all. Quite unusual. Is likely to appreciate it for those who add forums or anything, site theme . a tones way for your client to communicate. Nice task..

  144. I just like the helpful info you supply for your articles. I’ll bookmark your blog and take a look at once more right here regularly. I’m slightly sure I will learn many new stuff right right here! Best of luck for the next!

  145. Do you mind if I quote a couple of your posts as long as I provide credit and sources back to your weblog? My blog is in the very same niche as yours and my users would truly benefit from some of the information you provide here. Please let me know if this ok with you. Thanks!

  146. Howdy very nice blog!! Guy .. Excellent .. Amazing .. I’ll bookmark your blog and take the feeds additionally¡KI am glad to search out a lot of helpful information right here within the submit, we want work out extra techniques on this regard, thanks for sharing. . . . . .

  147. It’s a pity you don’t have a donate button! I’d definitely
    donate to this fantastic blog! I guess for now
    i’ll settle for bookmarking and adding your RSS feed to my Google account.
    I look forward to brand new updates and will share this site with my
    Facebook group. Talk soon!

  148. Wonderful beat ! I wish to apprentice while you amend your web site, how could i subscribe for a blog website? The account aided me a acceptable deal. I had been a little bit acquainted of this your broadcast provided bright clear concept

  149. Do you mind if I quote a couple of your posts as long as I provide credit and sources back to your site? My website is in the very same niche as yours and my users would really benefit from some of the information you present here. Please let me know if this ok with you. Cheers!

  150. I was just seeking this information for some time. After six hours of continuous Googleing, finally I got it in your website. I wonder what’s the lack of Google strategy that don’t rank this kind of informative websites in top of the list. Normally the top web sites are full of garbage.

  151. What i do not realize is in fact how you are now not actually much more smartly-appreciated than you may be right now. You’re very intelligent. You recognize thus significantly in terms of this matter, produced me in my opinion imagine it from a lot of numerous angles. Its like women and men don’t seem to be fascinated until it is something to do with Woman gaga! Your own stuffs outstanding. Always take care of it up!

  152. Excellent post. I was checking continuously this blog and I’m impressed! Extremely helpful information particularly the last part 🙂 I care for such information a lot. I was seeking this certain info for a very long time. Thank you and good luck.

  153. I definitely wanted to send a brief comment in order to thank you for those awesome guidelines you are giving here. My long internet research has at the end been compensated with beneficial ideas to share with my neighbours. I ‘d declare that we readers actually are really blessed to dwell in a very good network with very many outstanding professionals with insightful opinions. I feel truly fortunate to have seen your webpages and look forward to tons of more thrilling moments reading here. Thank you once again for a lot of things.

  154. I’m really impressed with your writing skills as well as with the layout on your weblog. Is this a paid theme or did you customize it yourself? Either way keep up the nice quality writing, it is rare to see a nice blog like this one these days..

  155. I do not know whether it’s just me or if perhaps everyone else experiencing issues with your website. It appears as though some of the written text on your posts are running off the screen. Can someone else please provide feedback and let me know if this is happening to them too? This might be a problem with my browser because I’ve had this happen before. Many thanks

  156. I have been surfing on-line greater than three hours lately, but I by no means discovered any interesting article like yours. It is pretty worth sufficient for me. In my view, if all webmasters and bloggers made just right content material as you probably did, the internet can be a lot more helpful than ever before.

  157. Whats up very cool blog!! Guy .. Excellent .. Amazing .. I will bookmark your web site and take the feeds additionally¡KI’m glad to search out numerous helpful information right here within the put up, we want work out more techniques on this regard, thanks for sharing. . . . . .

  158. I’ve been surfing online greater than three hours lately, but I never discovered any attention-grabbing article like yours. It¡¦s pretty value enough for me. Personally, if all website owners and bloggers made excellent content material as you did, the net will probably be a lot more useful than ever before.

  159. I do not know if it’s just me or if everybody else encountering problems with your website. It appears as if some of the text within your content are running off the screen. Can someone else please comment and let me know if this is happening to them as well? This could be a issue with my internet browser because I’ve had this happen previously. Appreciate it

  160. hey there and thank you for your info – I have certainly picked up anything new from right here. I did however expertise a few technical points using this web site, as I experienced to reload the site lots of times previous to I could get it to load properly. I had been wondering if your web host is OK? Not that I am complaining, but slow loading instances times will sometimes affect your placement in google and can damage your high quality score if advertising and marketing with Adwords. Anyway I am adding this RSS to my e-mail and can look out for much more of your respective intriguing content. Ensure that you update this again very soon..

  161. I was just searching for this info for some time. After 6 hours of continuous Googleing, finally I got it in your website. I wonder what is the lack of Google strategy that do not rank this kind of informative websites in top of the list. Normally the top sites are full of garbage.

  162. Thanks for the sensible critique. Me and my neighbor were just preparing to do some research on this. We got a grab a book from our area library but I think I learned more clear from this post. I am very glad to see such wonderful information being shared freely out there.

  163. hey there and thank you for your info – I have definitely picked up something new from right here. I did however expertise a few technical points using this website, since I experienced to reload the website lots of times previous to I could get it to load properly. I had been wondering if your web hosting is OK? Not that I’m complaining, but slow loading instances times will sometimes affect your placement in google and can damage your high-quality score if ads and marketing with Adwords. Well I’m adding this RSS to my email and could look out for much more of your respective interesting content. Make sure you update this again soon..

  164. I do not know whether it’s just me or if perhaps everyone else encountering issues with your blog. It appears like some of the written text within your content are running off the screen. Can someone else please provide feedback and let me know if this is happening to them too? This could be a issue with my internet browser because I’ve had this happen before. Thanks

  165. I don’t know if it’s just me or if perhaps everyone else encountering problems with your website. It looks like some of the text on your posts are running off the screen. Can someone else please comment and let me know if this is happening to them as well? This may be a problem with my browser because I’ve had this happen before. Thank you

  166. Hmm it appears like your blog ate my first comment (it was super long) so I guess I’ll just sum
    it up what I wrote and say, I’m thoroughly enjoying
    your blog. I too am an aspiring blog writer but I’m still new to the whole thing.
    Do you have any points for rookie blog writers? I’d definitely appreciate
    it.

  167. Pretty section of content. I just stumbled upon your blog and in accession capital to assert that I get in fact enjoyed account your blog posts. Any way I will be subscribing to your feeds and even I achievement you access consistently rapidly.

  168. I’m really impressed with your writing skills and also with the layout on your blog. Is this a paid theme or did you modify it yourself? Anyway keep up the excellent quality writing, it is rare to see a great blog like this one these days..

  169. It’s appropriate time to make some plans for the future and it’s time to be happy. I have read this post and if I could I desire to suggest you few interesting things or tips. Maybe you can write next articles referring to this article. I wish to read even more things about it!

  170. hello there and thank you for your information – I have definitely picked up anything new from right here. I did however expertise a few technical issues using this website, as I experienced to reload the site a lot of times previous to I could get it to load properly. I had been wondering if your web host is OK? Not that I’m complaining, but slow loading instances times will often affect your placement in google and can damage your high quality score if advertising and marketing with Adwords. Anyway I am adding this RSS to my email and can look out for a lot more of your respective exciting content. Ensure that you update this again very soon..

  171. I simply wanted to appreciate you all over again. I am not sure what I would’ve implemented without those tactics shown by you directly on such a problem. Entirely was a very challenging condition in my position, nevertheless noticing this professional avenue you managed the issue took me to leap with happiness. I am just grateful for the advice and then wish you realize what an amazing job you’re doing educating many people by way of a blog. I am certain you haven’t met all of us.

  172. SEO Sio Ajansı
    Kolayca ulaşabileceğiniz bir SEO hizmeti için internet üzerinden size çok geniş imkânlar hazırlanmış durumdadır. İnternet kullanan milyarlarca insanın arama motoru optimizasyonu ile birlikte bu çözümlere daha yakından bakma gereği dikkat çekiyor. Özellikle web sitelerinin gelişim ile beraber ön sırada olmasını sağlamak, bir SEO uzmanı çalışmasını gerekli hale getirmektedir.
    Burada profesyonel ekiplerin elbette daha önceden kullandığı ve başarılı olduğu yöntemler vardır. Alacağınız bir teknik yardım ile birlikte web sitenizi çok daha iyi bir yere getirmeniz mümkün olmaktadır. Giderek gelişmiş kurumsal SEO çalışması ile birlikte, özellikle firmaların daha iyi bir yere gelmesi planlanıyor ve hatta bu bir gerçeğe dönüşüyor. Bir hayali gerçeğe dönüştürmek konusunda yapılan çalışmalar, yatırımların gerçek karşılığını gösterme noktasında çok iyi bir çözüm üretiyor. İşin bir de ticaret boyut olmakla beraber, e-ticaret SEO bu konuda yine üzerinde durmanız gereken konulardan birini göstermektedir. Profesyonel olarak işine dört elle sarılmak uzmanların, bu konuda size sağlamış olduğu imkânlar ve hizmetler kesinlikle sona ermiyor.
    Adwords çalışmaları tanıtım ve reklam konusundaki destek ile birlikte, bu platformu çok daha verimli bir şekilde kullanmak sizin için mümkün olmaktadır. Adeta aynı zamanda dijital pazarlama enstrümanlarını en iyi şekilde kullanan sistem, arama motoru optimizasyonu ile birlikte çok daha geniş potansiyeli bir hizmeti ön plana taşıyor. İletişime geçtiğiniz donanımlı bir SEO ajansı ile birlikte bundan sonraki süreçlerde daha büyük avantajlar ve daha kapsamlı sonuçlar sizi bekliyor olacaktır.
    Hemen iletişime geçmeniz halinde donanımlı bir firmanın seo yardımını talep edebilirsiniz. Burada hizmet ve yardım talebinizi SEO Uzmanlarımız sizlere 7/24 destek vermekeyiz.
    SEO Sio Ajansı
    Gümüşsuyu Mahallesi, Dünya Sağlık Sk., 34437 Beyoğlu/İstanbul/Türkiye

  173. Today, I went to the beachfront with my kids. I found a sea
    shell and gave it to my 4 year old daughter and said “You can hear the ocean if you put this to your ear.”
    She put the shell to her ear and screamed. There was a hermit crab inside and it pinched her ear.
    She never wants to go back! LoL I know this is totally off topic but I had to tell someone!

  174. Pretty section of content. I just stumbled upon your site and in accession capital to assert that I get actually enjoyed account your blog posts. Anyway I will be subscribing to your augment and even I achievement you access consistently quickly.

  175. I would like to express my appreciation for your kindness in support of those who really want guidance on this important topic. Your personal commitment to getting the message across appears to be extraordinarily effective and has continually allowed those much like me to attain their dreams. Your amazing warm and helpful suggestions implies this much to me and somewhat more to my office colleagues. Regards; from each one of us.

  176. Hello there, just became alert to your blog through Google, and found that it is truly informative. I’m gonna watch out for brussels. I’ll be grateful if you continue this in future. Many people will be benefited from your writing. Cheers!

  177. I like what you guys are up too. Such intelligent work and reporting! Carry on the superb works guys I¡¦ve incorporated you guys to my blogroll. I think it will improve the value of my site 🙂

  178. Hi! I could have sworn I’ve visited your blog before but after looking at many of the posts I
    realized it’s new to me. Nonetheless, I’m definitely happy I came across it and
    I’ll be bookmarking it and checking back often!