Tuesday, November 6, 2007

Conjoined Twins Separation at Stanford Hospital


Hey everyone,

Lucile Packard Children's Hospital at Stanford University will be separating conjoined twins next Monday. They share a right atrium - which is really rare. We will have to place both kids on bypass, cut there hearts apart, move them to separate rooms, and then begin repairing their hearts. CRAZY!!! We have been preparing for this procedure for a long time and are very excited.

I added some info from Lucile Packard's website (this is not a violation of patient confidentiality) so you can read more about them. I will post more Monday night.

Ed


The following is from www.lpch.org


Yurelia Anyolett and Fiorella Gianina Rocha-Arias are conjoined twins. They were born in August 2005 in San Jose, Costa Rica.

Yurelia and Fiorella are joined at the chest and abdomen and face each other. This is called a thoraco-omphalopagus connection.

Additionally:
-Their livers are fused together into a single organ.
-The right atriums of their hearts are connected. The right atrium of the heart receives oxygen-poor (venous) blood from the body. Blood then goes through the right ventricle and into the lungs to get more oxygen.

Yurelia has a congenital heart problem (occurred as the heart formed during pregnancy). It is called double outlet right ventricle (DORV). The aorta and pulmonary artery are both connected to the right ventricle. Normally, the aorta is connected to the left ventricle. Despite the DORV, both of Yurelia’s ventricles are of normal size and function well. The DORV will require correction after the separation surgery.
Fiorella has pulmonary artery stenosis – a narrowing of her left main pulmonary artery. This will require correction after the separation surgery. Fiorella also has a thick right ventricle and high blood pressure.

Some blood is shared between the girls. The blood goes back and forth through connections in the heart and liver.
Fiorella’s body and organs are larger than Yurelia’s.

Yurelia and Fiorella will be 2 years old at the time of the surgery, they may be stronger and better able to recover after surgery. However, their age also means they’ve spent a longer time connected. Some muscle and skeleton changes have probably occurred that may make the actual separation or recovery more difficult.
The twins’ stay in the United StatesMending Kids International, a volunteer organization dedicated to providing complex surgical care to children outside the United States, arranged for the girls to come to Packard Children’s Hospital. Yurelia and Fiorella arrived in the United States on July 25. Their evaluation at Packard Children’s Hospital started the next day.



These are some good answers to Frequently Asked Questions.


1. How common are conjoined twins?The worldwide occurrence of conjoined twins is not well recorded. The frequency of conjoined twins is estimated to be between 1 in 30,000 to 1 in 200,000 worldwide. Because they occur so rarely, it is difficult to determine an exact frequency. Most do not survive pregnancy, and most who are born alive do not survive for more than 24 hours.

2. What causes conjoined twins?There are two theories about the forming of conjoined twins. The first is that a single fertilized egg does not totally split during the process of forming identical twins. The second theory is that a fusion of two fertilized eggs occurs earlier in development. Although conjoined twinning has not been linked to any environmental or genetic cause, they occur so rarely it has been impossible to draw firm conclusions.

3. How often is separation surgery performed?Separation surgery is performed in the United States about five times a year. Most recently, on August 29, 2007, physicians at the Children’s Hospital of Philadelphia separated 1-year-old conjoined twins who were joined at the abdomen.

4. Has a separation surgery ever been performed at Packard Children’s? What is the history of conjoined twin surgeries in the Bay Area?Yurelia and Fiorella Rocha-Arias will be the first set of conjoined twins separated at Lucile Packard Children’s Hospital. Prior to the opening of Packard Children's in 1991, two sets of twins were separated at Stanford Hospital & Clinics. Dr. Gary Hartman, the lead surgeon for Yurelia and Fiorella’s separation, was also involved in the prior two surgeries.The University of California at San Francisco and Children’s Hospital & Research Center Oakland have both performed surgical separations of conjoined twins.

5. What experience does the medical team at Packard Children’s have with conjoined twins?This will be the fifth separation of conjoined twins for lead surgeon Gary Hartman, MD. Cardiothoracic surgeon Frank Hanley, MD, has also been involved in separations of conjoined twins.

6. What is the survival rate for separation surgeries?Survival rates for twins joined primarily at the chest, known as thoraco-omphalopagus twins, are dependent on the complexity of the heart connection and any complications related to the separation of the liver. It is estimated that the survival rate for this type of separation surgery, for both twins, is approximately 50 percent.

7. Why is Packard Children’s performing this surgery?As one of the leading children’s hospitals in the nation, Packard Children’s has a strong record of successful outcomes in cases of high acuity. Physicians and surgeons at Packard Children’s have carefully evaluated Yurelia and Fiorella, and determined that in this case a successful separation is possible. With the experience of lead surgeon Gary Hartman together with experts from our Children’s Heart Center, Packard Children’s has the expertise to pursue the best possible outcome.

8. Who is paying for Yurelia and Fiorella’s medical care?Surgeons and physicians at Packard Children’s are donating their time and expertise to treat Yurelia and Fiorella. Additionally, Packard Children’s is providing medical and clinical care at no cost to Yurelia and Fiorella’s family. The Hospital does not discuss specific costs of procedures publicly. Mending Kids International has arranged for the children’s transportation and housing. Gifts in support of Packard Children’s Hospital and the expert care it gives to children like Yurelia and Fiorella who are undergoing complex surgery can be made by visiting http://twins.lpch.org and clicking the How to Help link.

9. Who will be involved in this surgery?Two comprehensive care teams—one for each girl—with representatives from nursing, anesthesia, cardiothoracic surgery, pediatric general surgery, plastic surgery, cardiac bypass specialists (THAT'S ME) and others, will be in the operating room throughout the entire procedure. After separation, the girls will be moved to separate operating tables and the teams will complete surgery with their respective patient. In addition to the surgical teams, the case will involve radiologists, critical care specialists, infectious disease experts, social workers, chaplains and many more. Basically every discipline in the hospital will be involved with the girls’ care.

10. How does treating a case like this change the usual logistics in the operating room?In separating conjoined twins, one surgical field becomes two; the surgical team must then divide and treat their respective patients, possibly in separate operating rooms. This requires two complete teams and two complete sets of equipment from the beginning.

11. Does the case present special anesthesia challenges?Yes. In general, pediatric cardiac anesthesia demands a thorough understanding of how individual structural abnormalities may affect the delivery and the metabolism of surgical anesthetics. This concern is compounded in the case of conjoined twins, who share a blood supply. A team of five anesthesiologists will monitor the twins—two per girl plus one additional team member—during the separation process. Although anesthesia administered to one of the girls affects both, each child will be individually anesthetized from the beginning of the surgery to prepare for the separation and to enable the anesthesiologists to quickly and accurately meet the needs of each child as their connection is gradually separated.

12. What are the risks for the surgery?As in every surgical procedure, there are factors that can cause complications or even death. In this specific situation, there are additional risks of cardiac dysfunction due to the necessary separation and reconstruction of the hearts, of excess bleeding during the separation of the liver, of injury to the gall bladder and bile ducts, and of respiratory problems due to the reconstruction of the girls’ chest after separation.

68 comments:

KiMnRoB said...

It is mindblowing how far science has come along... Glad to see you have a husband who is dedicated towards saving the world one person at a time!
FYI-
You've been tagged. Check out my blog for details.

The Wades said...

good luck ed, that's amazing! looks like they have the right people there for the job!

Molly said...

I read about them a while back and I'm really excited that the surgery is coming up and that you'll be part of it! It's fun to see what goes on here at Stanford and it's exciting to know that I'm helping the students who will one day be doing these kinds of procedures. It's just amazing that we can do these kinds of things now!

KaylynnCallister said...

Wow, that is unbelieveable that you will get to be part of such a surgery! Good look! You are awesome.

Anonymous said...

interstitial cystitis diet for [url=http://usadrugstoretoday.com/categories/anti-acidity.htm]anti acidity[/url] adp oxford health insurance http://usadrugstoretoday.com/products/protonix.htm tower crane erection http://usadrugstoretoday.com/products/hyaluronic-acid.htm
fda guidlines viral assays [url=http://usadrugstoretoday.com/products/accutane.htm]accutane[/url] missouri bureau of emergency medical services dnr request [url=http://usadrugstoretoday.com/products/aciclovir.htm]master muscle worship domination[/url]

Anonymous said...

healthy blood sugar range [url=http://usadrugstoretoday.com/products/prazosin.htm]prazosin[/url] chiropractors blend muscle ease http://usadrugstoretoday.com/products/aciphex.htm clomid luteal phase length http://usadrugstoretoday.com/products/kamasutra-intensity-condoms.htm
sleeping bag perth airport [url=http://usadrugstoretoday.com/products/ayurslim.htm]ayurslim[/url] green tea pearland texas [url=http://usadrugstoretoday.com/categories/men-s-health.htm]ibs diet plan[/url]

Anonymous said...

number of people recorded on drugs [url=http://usadrugstoretoday.com/products/gasex.htm]gasex[/url] new braunfels health http://usadrugstoretoday.com/products/yasmin.htm polio vaccine booster dosage http://usadrugstoretoday.com/products/prednisolone.htm
drug addict gets fried [url=http://usadrugstoretoday.com/products/ilosone.htm]ilosone[/url] vermont health clubs [url=http://usadrugstoretoday.com/products/wellbutrin-sr.htm]health and equitable communities guidebook[/url]

Anonymous said...

http://newrx.in/anastrozole/anastrozole-pathology
[url=http://newrx.in/carbidopa/migraine-headaches-cafergot]viagra forum[/url] pharmacy technician state certification in illinois [url=http://newrx.in/anastrozole/arimidex-anastrozole]arimidex anastrozole[/url]
schwartzneger dope drug http://newrx.in/xeloda/chemo-pills-pancreatic-cancer-xeloda
[url=http://newrx.in/leflunomide/leflunomide]cialis from india[/url] what are depresenat drugs and what can they do to the body [url=http://newrx.in/disopyramide/disopyramide-clinical]disopyramide clinical[/url]
people who do drugs are stupid http://newrx.in/escitalopram/is-escitalopram-a-benzodiazepine
[url=http://newrx.in/xanax/xanax-high]should you be taking cialis when you are taking flomax[/url] dysfunction erectile vacuum [url=http://newrx.in/whitening/teeth-whitening-review]teeth whitening review[/url] best practices alcohol drugs and mental health canada [url=http://newrx.in/cetirizine/cetirizine-chewable-tablets]cetirizine chewable tablets[/url]

Anonymous said...

certified medical coding [url=http://usadrugstoretoday.com/categories/general-de-salud.htm]general de salud[/url] cleanse diet http://usadrugstoretoday.com/products/doxycycline.htm dollhouse medicine hat http://usadrugstoretoday.com/#first
dna isolation from blood ppt [url=http://usadrugstoretoday.com/products/bactroban.htm]bactroban[/url] theater army medical materiel information system [url=http://usadrugstoretoday.com/products/arava.htm]mkamenstein tea kettle tuxedo[/url]

Anonymous said...

http://online-health.in/anxiety/anxiety-children-self-help-book
[url=http://online-health.in/asthma/medical-treatments-for-asthma]drug dealler 4[/url] online pharmacy that takes insurance [url=http://online-health.in/asthma/asthma-diet-natural-treatment]asthma diet natural treatment[/url]
pharmacy school in new jersey http://online-health.in/bisacodyl/bisacodyl-tablets-5mg
[url=http://online-health.in/antidiabetic/antidiabetic-drug-with-fda-safety-alert]drug biodistribution[/url] fraud in pharmacy [url=http://online-health.in/arava]arava[/url]
temple university school of pharmacy http://online-health.in/biaxin/pediatric-biaxin
[url=http://online-health.in/ashwagandha]maxine waters drugs black neighborhoods[/url] online levitra dream pharmaceutical [url=http://online-health.in/bactroban/prophylactic-use-of-bactroban-determining-need]prophylactic use of bactroban determining need[/url] drug list that interfere with coumadin [url=http://online-health.in/avodart/casodex-and-avodart-together]casodex and avodart together[/url]

Anonymous said...

http://xws.in/acomplia/buy-acomplia
[url=http://xws.in/acyclovir/systemic-acyclovir-is-effective-in-herpes-zoster-ophthalmicus]bi lo pharmacy[/url] chinese medicine skin meridians [url=http://xws.in/domperidone/domperidone-lc-ms]domperidone lc ms[/url]
levitra no prescription discount cialis discount c http://xws.in/aceon/generic-names-for-accupril-40mg
[url=http://xws.in/alendronate/alendronate-fosamax]fedelis health care[/url] find prescription drugs online [url=http://xws.in/altace/altace-drugstore-effect]altace drugstore effect[/url]
will adderall affect the results of drug testing http://xws.in/actonel
[url=http://xws.in/elavil/elavil-migraine]origin of pharmacy[/url] how to cheat on a drug test [url=http://xws.in/dulcolax/dulcolax-with-oxycotin]dulcolax with oxycotin[/url] florida pharmacy laws 2007 [url=http://xws.in/doxepin/drug-images-doxepin]drug images doxepin[/url]

Anonymous said...

http://healthboard.in/bust/bust-32g
[url=http://healthboard.in/coumadin/granite-coumadin-clinic]pretrial drug testing[/url] erectile herbal remedies [url=http://healthboard.in/bodybuilding/bodybuilding-colorad]bodybuilding colorad[/url]
non formulry drugs http://healthboard.in/bust/extacy-surfboard-bust
[url=http://healthboard.in/cozaar/avapro-side-effects-different-from-cozaar]rite aide drugstore[/url] drug effects reticular activating system [url=http://healthboard.in/cytotec/compra-em-curitiba-de-cytotec]compra em curitiba de cytotec[/url]
anticholinergic drugs http://healthboard.in/coumadin/food-to-avoid-if-taking-coumadin
[url=http://healthboard.in/colchicine/colchicine-and-digestive-problems]clinical trials for diabetes drugs in china[/url] cause for erectile disorder [url=http://healthboard.in/desyrel/side-effects-of-desyrel]side effects of desyrel[/url] mike smith of nashua nh arrested for drugs nh [url=http://healthboard.in/cytotec/inductional-with-cytotec]inductional with cytotec[/url]

Anonymous said...

http://meen.in/cialis/cialis-canada
[url=http://meen.in/esomeprazole/esomeprazole-injections-ppt]best discount drug company[/url] top 10 prescribed drugs 2006 [url=http://meen.in/clavulanate/amoxicillin-clavulanate-potassium]amoxicillin clavulanate potassium[/url]
cieh health and safety course http://meen.in/cilostazol/cyklokapron
[url=http://meen.in/fluoxetine/fluoxetine-lovesick]merx tablet drug[/url] anger drugs [url=http://meen.in/erythromycin/erythromycin-ethylhexanoate]erythromycin ethylhexanoate[/url]
partnership for a drug free new jesey http://meen.in/cardizem/cardizem-arterectomy
[url=http://meen.in/ezetimibe/ezetimibe-10]walk in pharmacy versus onlin pharmacy[/url] hy vee drugstore 1st ave [url=http://meen.in/fluticasone/fluticasone-solumeterole]fluticasone solumeterole[/url] cialis tadalis tadalafi nurofen plus [url=http://meen.in/erythromycin/how-does-erythromycin-kill-bacteria]how does erythromycin kill bacteria[/url]

Anonymous said...

http://poow.in/melatonin/melatonin-depression
[url=http://poow.in/methylprednisolone/methylprednisolone-given-to-pregnant-21-weeks]health latinas[/url] start up pharmacy business plan [url=http://poow.in/letrozole/how-long-can-you-take-letrozole]how long can you take letrozole[/url]
stereotype black male drug dealer http://poow.in/lamivudine/lamivudine-zidovudine
[url=http://poow.in/rhinocort/rhinocort-gave-me-a-headache]oils for health crylic[/url] drug sale [url=http://poow.in/ribavirin/ribavirin-death]ribavirin death[/url]
drug x http://poow.in/lasix/lasix-with-an-ace-pelt
[url=http://poow.in/mestinon/usual-dose-of-mestinon-for-myasthenia]when did people start using drugs[/url] diet drugs and thyroid condition [url=http://poow.in/glaucoma/glaucoma-tucson]glaucoma tucson[/url] arial pharmacy [url=http://poow.in/glaucoma/glaucoma-fellowship]glaucoma fellowship[/url]

Anonymous said...

mercedes benz c320 http://automotoportal.in/opel/papermodel-opel-gt mercedes benz car dealers in delaware
[url=http://automotoportal.in/radiator/pt-cruiser-radiator-parts]pursuing a claim against a private automobile seller[/url] italian auto speed record [url=http://automotoportal.in/scion/salvaged-used-scion-tc-for-sale]salvaged used scion tc for sale[/url]
mercedes emblems http://automotoportal.in/opel/opel-manta-gte
[url=http://automotoportal.in/yamaha/yamaha-replacement-horn]automobile shipping weights[/url] auto rental age 23 [url=http://automotoportal.in/pontiac/pontiac-g6-and-intermediate-steering-shaft-problems]pontiac g6 and intermediate steering shaft problems[/url]
volkswagen bike rack http://automotoportal.in/radiator/how-to-clean-a-radiator-at-home
[url=http://automotoportal.in/scooter/ohio-scooter-license]automobile fuel pumps[/url] automobile sunroof repairs columbus ohio [url=http://automotoportal.in/motors/emerson-5-hp-electric-motors]emerson 5 hp electric motors[/url]

Anonymous said...

noblesville indiana auto http://eautoportal.in/buick/discount-buick-century-parts nassau county forfeiture automobile district attorney rice
[url=http://eautoportal.in/jaguar/jaguar-paint-code]automobile safety information[/url] apr after bankruptcy automobile [url=http://eautoportal.in/ford-auto/ford-shock-mounts-on-a-yj]ford shock mounts on a yj[/url]
auto appraiser course http://eautoportal.in/honda-motorcycle/savage-ls650-motorcycle-rims
[url=http://eautoportal.in/ford-car/unionville-chadds-ford]richmond auto insurance[/url] mercedes of godfrey [url=http://eautoportal.in/buick/schumacher-buick]schumacher buick[/url]
cost to safety certify an automobile ontario http://eautoportal.in/geo/geo-tracker-fender
[url=http://eautoportal.in/daihatsu/daihatsu-sirian]volkswagen jetta custom[/url] traps auto parts [url=http://eautoportal.in/chevrolet/chevrolet-buick-enclave]chevrolet buick enclave[/url]

Anonymous said...

orchards travel agency http://livetravel.in/cruises/hawaii-cruises-from-tampa travel booking search engines
[url=http://livetravel.in/inn/coonawarra-motor-inn-penola]passport gay travel magazine[/url] california travel news [url=http://livetravel.in/inn/sayre-mansion-inn]sayre mansion inn[/url]
travel doc hillcrest http://livetravel.in/airport/air-fare-moline-international-airport
[url=http://livetravel.in/tour/eagles-1977-tour-dates]queer travel[/url] madrid travel [url=http://livetravel.in/maps/command-and-conquer-zero-hour-maps]command and conquer zero hour maps[/url]
travel message board http://livetravel.in/cruise/how-to-cancel-cruise-reservations
[url=http://livetravel.in/airline/robert-ainsworth-airline-pilot]eugene of travel fame[/url] libert travel [url=http://livetravel.in/flight/pilot-flight-kit]pilot flight kit[/url] selling my asian travel club membership [url=http://livetravel.in/cruise/viking-cruise-lines]viking cruise lines[/url]
learning nomadic travel techniques [url=http://livetravel.in/car-rental/child-seat-coupons-and-car-rental]child seat coupons and car rental[/url]
reviews on ace golf travel bags http://livetravel.in/motel/motel-albuquerque-airport
[url=http://livetravel.in/airlines/southwest-airlines-shamu-diecast-aircraft]holiday travel deals airlines[/url] travel and tourist bureau in florida [url=http://livetravel.in/vacation-packages/cancun-vacation-package]cancun vacation package[/url]
[url=http://livetravel.in/tourism/st-albans-tourism]st albans tourism[/url] powerline global power travel voltage converter [url=http://livetravel.in/hotel/dfw-to-lga-flight-hotel-deals]dfw to lga flight hotel deals[/url] australian travel restrictions [url=http://livetravel.in/flight/flight-jackets-alpha]flight jackets alpha[/url]
bus line travel [url=http://livetravel.in/motel/boots-motel]boots motel[/url]

Anonymous said...

travel nursing torrance housing http://greatadventures.in/airport book buddy travel
[url=http://greatadventures.in/lufthansa/oasis-hong-kong-airways]costa rica swiss travel[/url] east coast travel info [url=http://greatadventures.in/inn/comfort-inn-ocean-front]comfort inn ocean front[/url]
travel volcity http://greatadventures.in/map/michigan-hiighway-map
[url=http://greatadventures.in/travel/what-is-the-travel-use-in-the-african-great-rift-valley]gay travel and resorts in the caribbean[/url] travel sinai wadis [url=http://greatadventures.in/travel/travel-with-teens]travel with teens[/url]
mexico travel guide http://greatadventures.in/map/map-of-dover-docks travel guide british columbia tourism [url=http://greatadventures.in/airport/airport-fire-supression]airport fire supression[/url]

Anonymous said...

capital one auto address http://autoexpress.in/oldsmobile/changing/oil/oldsmobile/intrigue mercedes e class hearse
[url=http://autoexpress.in/mercury/mercury/marauder/accessories]used mercedes cars[/url] volkswagen passat 2005 [url=http://autoexpress.in/motors/small/dc/motors/surplus]small dc motors surplus[/url]
dodge tiger 2 http://autoexpress.in/mazda/mazda/tribute/bumper/cover
[url=http://autoexpress.in/cadillac/cadillac/engine/56]brunhoezzl racing[/url] national automobile association [url=http://autoexpress.in/plymouth/pets/and/aquarium/plymouth]pets and aquarium plymouth[/url]
raybestos auto parts http://autoexpress.in/radiator/atlanta/radiator
[url=http://autoexpress.in/saab/saab/transmission/kit]serpintine belt dodge caravan[/url] kissel automobile [url=http://autoexpress.in/buell/buell/theator]buell theator[/url]

Anonymous said...

nashville hawaii travel deals http://livetravel.in/motel/shawnee-inn-motel usairways travel alert
[url=http://livetravel.in/cruises/starlight-cruises-melody]ganz travel[/url] travel trailer houston texas [url=http://livetravel.in/hotel/arenal-manoa-hotel]arenal manoa hotel[/url]
u travel http://livetravel.in/expedia/hotel-motel-orlando-florida-airport-expedia
[url=http://livetravel.in/motel/exterior-corridor-motel]humacao pr travel[/url] snap in travel mug [url=http://livetravel.in/airline/find-the-best-prices-for-airline-ickets]find the best prices for airline ickets[/url]
travel wireless internet http://livetravel.in/tour/international-tour-companies-in-australia
[url=http://livetravel.in/plane-tickets/plane-tickets-to-85051]courses to become a travel agent[/url] women travel tours [url=http://livetravel.in/plane-tickets/plane-tickets-to-greece]plane tickets to greece[/url] ellis harley travel uk [url=http://livetravel.in/tourism/seattle-washington-tourism]seattle washington tourism[/url]
poweron board travel cooler [url=http://livetravel.in/airlines/check-flight-times-for-hawaiin-airlines]check flight times for hawaiin airlines[/url]
used travel trailers florida http://livetravel.in/tour/wine-tour-weekends
[url=http://livetravel.in/disneyland/visit-disneyland]times travel lahore[/url] travel ile ife osun [url=http://livetravel.in/adventure/fancy-pants-adventure-cheats]fancy pants adventure cheats[/url]
[url=http://livetravel.in/inn/ramada-inn-denton]ramada inn denton[/url] month travel [url=http://livetravel.in/airline/airline-reservation-system-er-diagram-logical-model]airline reservation system er diagram logical model[/url] ferry boat travel guide [url=http://livetravel.in/tours/buenos-aires-sex-tours]buenos aires sex tours[/url]
homeland security travel [url=http://livetravel.in/plane-tickets/cheapest-plane-tickets-from-sandiego-to-las-vegas]cheapest plane tickets from sandiego to las vegas[/url]

Anonymous said...

needed auto mechanic skills http://autoexpress.in/porsche/porsche/melendez saiga 12 full auto
[url=http://autoexpress.in/peugeot/peugeot/406/cooling/fan/faults]mercedes abs light on code po720[/url] mercedes 280c [url=http://autoexpress.in/oldsmobile/oldsmobile/regency/98/form]oldsmobile regency 98 form[/url]
franfurt main mercedes car sale address http://autoexpress.in/pontiac/pontiac/osteopathic/hospital
[url=http://autoexpress.in/saab/saab/93/turbocharger]maintenance on a mercedes truck gear box[/url] auto parts vw [url=http://autoexpress.in/rally]rally[/url]
non owner auto insurance washington http://autoexpress.in/maybach
[url=http://autoexpress.in/maserati/los/angeles/maserati]jons auto[/url] ken schrader racing employment [url=http://autoexpress.in/oldsmobile/oldsmobile/aurora/coolant/leak]oldsmobile aurora coolant leak[/url]

Anonymous said...

designer purse knockoff http://topcitystyle.com/dolce-amp-gabbana-trendy-pants-grey-item1409.html teen preteen fashion models [url=http://topcitystyle.com/30-shorts-size12.html]death rituals shoes[/url] child fashion model photo
http://topcitystyle.com/navy-blue-sport-zip-jacket-and-pants-color21.html calamityjane shoes seventeen magazine [url=http://topcitystyle.com/light-purple-women-s-tops-color202.html]designer fashions[/url]

Anonymous said...

lauren crane nude http://topcitystyle.com/black-brown-on-sale-color163.html dsw shoes [url=http://topcitystyle.com/versace-casual-fall-spring-brand1.html]fashion high photographer[/url] high fashion model pics
http://topcitystyle.com/miss-sixty-casual-tops-brand25.html kleinfield bridal [url=http://topcitystyle.com/navy-blue-shirts-with-colar-color21.html]fashion myspace[/url]

Anonymous said...

lauren zammerilla http://topcitystyle.com/xs-dolce-amp-gabbana-size46.html photoes of chanel [url=http://topcitystyle.com/blue-and-grey-on-sale-color145.html]clothes stolen naked[/url] dance shoes
http://topcitystyle.com/dolce-amp-gabbana-tank-top-beige-item410.html wrestling shoes marietta ohio [url=http://topcitystyle.com/multi-casual-color71.html]pleaser shoes[/url]

Anonymous said...

superman shoes http://topcitystyle.com/cream-women-s-tops-color68.html z coil shoes [url=http://topcitystyle.com/roberto-cavalli-charming-floral-blouse-item1933.html]course fees in fashion tech in singapore[/url] two lips lucite shoes
http://topcitystyle.com/d-amp-g-sport-pants-for-men-brown-item2313.html clothes dryers and multiple run [url=http://topcitystyle.com/grey-blue-women-color189.html]kelly interview shoes[/url]

Anonymous said...

sexy ktv http://planetofporn.in/fetish/fetish-nipples-puffy-sex
[url=http://planetofporn.in/adult-story/homemade-adult-costume-ideas]jasmin hentai[/url] gay porn flash games compliation [url=http://planetofporn.in/best-amateur/amateur-free-post-slut]amateur free post slut[/url]
spanish porn stars http://planetofporn.in/adult-video/motivating-adult-unemployed-learners
[url=http://planetofporn.in/erotic-video/online-erotic-short-stories]amateur videos sale[/url] adult cartoon free [url=http://planetofporn.in/ass-sex/bad-ass-browser]bad ass browser[/url]
adult video clips and cams http://planetofporn.in/fetish/sex-fetish-picture
[url=http://planetofporn.in/erotic-gay/erotic-x]free amateur straight guys[/url] donna marie porn [url=http://planetofporn.in/condom/huge-dildo-tiny-chick]huge dildo tiny chick[/url]
cuban amateur sex movies http://planetofporn.in/adult-movie/adult-story-sites-free-that-start-with-a
[url=http://planetofporn.in/ass-sex/hot-ass-teens]blu ray and adult[/url] intoxicated porn [url=http://planetofporn.in/bdsm/bdsm-suspendsd]bdsm suspendsd[/url]

Anonymous said...

buffalo adult ed http://xwe.in/adult-video/free-adult-video-downloads
[url=http://xwe.in/gay-anal/gay-picture-slide-show]las vegas adult entertainment review[/url] mc dark territory adult videos [url=http://xwe.in/condom/her-plesure-condoms]her plesure condoms[/url]
anal gland remedy http://xwe.in/thong/heart-shaped-butt-women-in-thong-pics
[url=http://xwe.in/oral/ell-oral-language]distributing legalized porn[/url] anime hentai pooping [url=http://xwe.in/toon/toon-breast-expansion-videos]toon breast expansion videos[/url]
amateur wife fuck http://xwe.in/erotic-gay/erotic-massage-in-milan
[url=http://xwe.in/blow/global-plastic-blow]amateur pics of naturally hairy vaginas[/url] free adult stockings galleries [url=http://xwe.in/thong/free-thong-pic-galleries]free thong pic galleries[/url]
pittsburgh adult educational resource http://xwe.in/bondage/water-bondage-clip
[url=http://xwe.in/shemale/shemale-lesbians-cumshot]deep dildo[/url] desi adult pics [url=http://xwe.in/fetish/boxing-fetish-sex]boxing fetish sex[/url]

Anonymous said...

mobile registry editor http://www.orderphonetoday.com/b100-quad-band-dual-card-with-java-unlocked--item60.html midland land mobile radio parts [url=http://www.orderphonetoday.com/g5-mini-quad-band-dual-card-with-wifi-analog-tv--item86.html]monophonic nokia composer mobile ringtones for 3330[/url] crack mobile assistant

Anonymous said...

black girls free movie [url=http://full-length-movies.com/dvd-quality-movie-chatterbox/26329database/]Chatterbox[/url] who stars in the movie seabiscuit [url=http://full-length-movies.com/dvd-quality-movie-star-trek-07---generations/3268database/]Star Trek 07 - Generations[/url]
sebring florida movie guide [url=http://full-length-movies.com/dvd-quality-movie-46-moments/2813database/]46 Moments[/url] movie major leauge [url=http://worldmovs.co.cc/full_version-legenden-fr--n-djupet/18164database/]Legenden Fr??n Djupet[/url]
ultimate avengers online full movie [url=http://full-length-movies.com/dvd-quality-movie-if..../23388database/]If....[/url] naruto shippuden the movie [url=http://worldmovs.co.cc/full_version-ghostbusters-ii/3556database/]Ghostbusters II[/url]
james garner movie in 2006 [url=http://worldmovs.co.cc/full_version-professione-reporter/27688database/]Professione Reporter[/url] saw iv movie info [url=http://full-length-movies.com/dvd-quality-movie-lust-caution/14330database/]Lust Caution[/url]

Anonymous said...

cole haan shoes for men http://luxefashion.us/?action=products&product_id=1838 sour shoes [url=http://luxefashion.us/springfield-brand109.html]comfortable work shoes[/url] laurens county sc public records
http://luxefashion.us/shoes-dolce-amp-gabbana-type4.html chacu shoes uk [url=http://luxefashion.us/s-tops-shirts-with-colar-size10.html]laurenceville correctional[/url]

Anonymous said...

mourning clothes http://www.thefashionhouse.us/coralline-women-color112.html the boston chanel [url=http://www.thefashionhouse.us/-sport-on-sale-category93.html]clothes sell online[/url] kenmore clothes dryer metal shudder type idler puley photos
http://www.thefashionhouse.us/dark-green-color49.html how to make your own clothes patterns [url=http://www.thefashionhouse.us/score-one-ply-windbreaker-jackets-brand75.html]designer eyeglasses black with crystal[/url]

Anonymous said...

penis wikipedia [url=http://usadrugstoretoday.com/bestsellers.htm]Pharmacy bestsellers[/url] medical conditons that effect diets http://usadrugstoretoday.com/categories/disfunzione-erettile.htm
extraction of calcium [url=http://usadrugstoretoday.com/products/prednisolone.htm]prednisolone[/url] frequency of sanfilippo syndrome [url=http://usadrugstoretoday.com/products/alavert.htm ]mental health public policy [/url] health care associates credit union
platypus penis hunter [url=http://usadrugstoretoday.com/products/omnicef.htm]omnicef[/url] blood diseases microfibrosis http://usadrugstoretoday.com/products/celadrin.htm
health benefits to delaying spay or neuter [url=http://usadrugstoretoday.com/products/viagra-soft-flavoured.htm]viagra soft flavoured[/url] the darkend heart [url=http://usadrugstoretoday.com/categories/erection-packs.htm ]cure for depression [/url] drug testing kendle

Anonymous said...

sizng chart shoes mondo http://www.thefashionhouse.us/red-beige-on-sale-color42.html babes take off their clothes [url=http://www.thefashionhouse.us/scarfs-amp-hats-accessories-category57.html]sanita shoes[/url] lauren kelley
http://www.thefashionhouse.us/3-years-new-size34.html fashioniasta [url=http://www.thefashionhouse.us/we-r-we-are-the-angels--v-neck-brand84.html]elk grove illinois catalog designers[/url]

Anonymous said...

dubuque health dept [url=http://usadrugstoretoday.com/products/septilin.htm]septilin[/url] where can you get genital herpes http://usadrugstoretoday.com/products/pro-erex.htm
breast implant surgeon dallas [url=http://usadrugstoretoday.com/products/brahmi.htm]brahmi[/url] electro vaginal play vidoe clips [url=http://usadrugstoretoday.com/products/voltaren.htm ]smoking regulatoins in oxford ms [/url] breast breast breast titts big
smoking loon [url=http://usadrugstoretoday.com/products/antabuse.htm]antabuse[/url] generic drug identification http://usadrugstoretoday.com/products/sumycin.htm
health insurance instant quotes [url=http://usadrugstoretoday.com/products/dilantin.htm]dilantin[/url] sleeping beauty porn [url=http://usadrugstoretoday.com/categories/artritis.htm ]extended health care columbia sc rice homes [/url] exlax recommended dosage

Anonymous said...

free breast pictures [url=http://usadrugstoretoday.com/products/furosemide.htm]furosemide[/url] drakeol mineral oil http://usadrugstoretoday.com/categories/gastrointestinale.htm
church health insurance [url=http://usadrugstoretoday.com/catalogue/i.htm]No prescription online pharmacy[/url] horizon health fitness [url=http://usadrugstoretoday.com/catalogue/i.htm ]online pharmacy levitra [/url] bacterial infection treatment
monthly health insurance payment deductible [url=http://usadrugstoretoday.com/products/keppra.htm]keppra[/url] free stress managment assesment http://usadrugstoretoday.com/products/generic-keflex.htm
triisopropyl borate osteoporosis drugs [url=http://usadrugstoretoday.com/products/tretinoin-cream-0-05-.htm]Buy Tretinoin Cream 0.05% Online[/url] dental coverage for mentally retarded people in pennsylvania [url=http://usadrugstoretoday.com/products/prednisolone.htm ]stress lightheaded [/url] acne remedy scalp acne birth control pill acne acne during

Anonymous said...

in theaters movie with blood in the title [url=http://usadrugstoretoday.com/products/proventil.htm]proventil[/url] medical clinics tulsa oklahoma http://usadrugstoretoday.com/products/parlodel.htm
penis castrations [url=http://usadrugstoretoday.com/products/avodart.htm]avodart[/url] number of amputations caused by diabetes [url=http://usadrugstoretoday.com/categories/montage-packs.htm ]cholesterol egg yolk mayo [/url] bodybuilding links
sentry dental care [url=http://usadrugstoretoday.com/products/glucotrol-xl.htm]glucotrol xl[/url] spencer institute health wellness http://usadrugstoretoday.com/categories/arthritis.htm
medical robotics [url=http://usadrugstoretoday.com/products/shallaki.htm]shallaki[/url] gummy vaginal discharge [url=http://usadrugstoretoday.com/catalogue/o.htm ]health statistics of genetic diseases [/url] what causes breast infection male

Anonymous said...

belks womens shoes http://www.thefashionhouse.us/burberry-bags-brand4.html robert land shoes [url=http://www.thefashionhouse.us/?action=products&product_id=1314]how to matching shoes with socks clothes[/url] wide tennis shoes
http://www.thefashionhouse.us/sweaters-dolce-amp-gabbana-category24.html australia fashions [url=http://www.thefashionhouse.us/-tank-tops-versace-category60.html]designer tees[/url]

Anonymous said...

outdoor soccer shoes http://www.thefashionhouse.us/t-shirts-for-men-page3.html prive los angeles laurent [url=http://www.thefashionhouse.us/?action=products&product_id=1312]mission statement interior designer[/url] golf clothes women
http://www.thefashionhouse.us/blue-jackets-amp-sweatshirts-color32.html final score shoes [url=http://www.thefashionhouse.us/36-women-s-tops-size14.html]web site designer software[/url]

Anonymous said...

http://xwv.in/ketoconazole/ketoconazole/pills/for/hair/loss
[url=http://xwv.in/oxybutynin/oxybutynin/uses]court ordered drug program results[/url] illegal drug discharge characterization for the army [url=http://xwv.in/kamagra/sltermarice/altwrnstibe/aocakos/bui/xidlua/jrk/jelly/kamagra]sltermarice altwrnstibe aocakos bui xidlua jrk jelly kamagra[/url]
naproxon false drug test http://xwv.in/oxybutynin/oxybutynin/overdose
[url=http://xwv.in/isotretinoin/pharmacokinetics/of/oral/isotretinoin]carson county drug busts[/url] girl health comic [url=http://xwv.in/pain-relief/frozen/shoulder/relief/pain]frozen shoulder relief pain[/url]
erectile dysfunction massage http://xwv.in/naprosyn/cost/of/naprosyn
[url=http://xwv.in/pantoprazole/pantoprazole/manufacture]positive drug tests and marijuana[/url] veterinary drugs plant [url=http://xwv.in/pain-relief/pain/relief/wrist]pain relief wrist[/url] federal statute pharmacy open to public warehouse club [url=http://xwv.in/pamelor/pamelor/off/label/use]pamelor off label use[/url]

Anonymous said...

camerons clothes the holiday http://topcitystyle.com/cream-navy-blue-sweaters-color162.html wholesale maternity clothes [url=http://topcitystyle.com/white-and-purple-sweaters-color147.html]susanne knips of dresdner kleinwort[/url] laboutin shoes
http://topcitystyle.com/pecci-sport-brand16.html acoustic designer [url=http://topcitystyle.com/cream-sky-blue-men-color153.html]head racquetball shoes[/url]

Anonymous said...

who made the edsel automobile http://pqx.in/aprilia/aprilia/parts/in/the/uk borg warner automobile floor planning
[url=http://pqx.in/maybach/bauart/maybach]auto control transformer[/url] altezza tail lights dodge truck [url=http://pqx.in/ford/gail/ford/john/bahrain]gail ford john bahrain[/url]
mercedes mb140d oil filter numbers http://pqx.in/bike/exercize/bike/reviews
[url=http://pqx.in/martin/aston/martin/v8/volante]texas automobile insurance law[/url] maine auto document fees [url=http://pqx.in/hummer/articles/hummer/dealership/building]articles hummer dealership building[/url]
buy volkswagen camper california http://pqx.in/buick/radio/in/an/buick/century/e11
[url=http://pqx.in/isuzu/washington/isuzu/commercial/truck/dealer]automobile inside outside thermometer[/url] how to pull auto door post [url=http://pqx.in/ferrari/ferrari/girls]ferrari girls[/url]

Anonymous said...

headliner automobile carpet repair and supplies http://xwm.in/dodge/dodge-ram-2500-crash-data-recorder jacksonville nc website all star auto sales
[url=http://xwm.in/radiator/pm-d7045-radiator-cap-pliers-uk]vw auto stick pressure plate[/url] no grip racing [url=http://xwm.in/daewoo/daewoo-cielo-workshop-manuals]daewoo cielo workshop manuals[/url]
automobile engine boat http://xwm.in/peugeot/how-to-fix-speedo-expert-peugeot
[url=http://xwm.in/radiator/vtx-1800-r-radiator-cover]diagram mercedes 420se belts[/url] lasalle auto wreckers [url=http://xwm.in/daewoo/daewoo-ddt21h9s-television]daewoo ddt21h9s television[/url]
life before the invention of the automobile http://xwm.in/porsche/moe-mistry-porsche
[url=http://xwm.in/car-racing/richard-chilldress-racing]gilleland auto[/url] mercedes benz g class suv [url=http://xwm.in/chevrolet/harbor-chevrolet]harbor chevrolet[/url]

Anonymous said...

jackpot arizona state numbers break lunch lottery web http://lwv.in/jokers/jokers-pic casino row biloxi ms 21 3
[url=http://lwv.in/keno/keno-rules-bonus]baccarat crystal[/url] blackjack sgh i 607 recalls [url=http://lwv.in/slots/tachi-casino-best-odds-slots]tachi casino best odds slots[/url]
play keno entertainment http://lwv.in/roulette/paniponi-roulette-roulette
[url=http://lwv.in/lottery]motelin jackpot nv[/url] joker and the thief backtrack [url=http://lwv.in/slot/mini-slot-machine]mini slot machine[/url]
laughlin casino entertainment http://lwv.in/casino-playing-cards/cezanne-men-playing-cards bingo napa california [url=http://lwv.in/poker-online/playmate-poker]playmate poker[/url]

Anonymous said...

movie scripts esl [url=http://moviestrawberry.com/films/film_sniper/]sniper[/url] wild wild west movie http://moviestrawberry.com/films/film_bodyguard_a_new_beginning/ patttttttlatoon movie
divx download free movie porn [url=http://moviestrawberry.com/films/film_one_million_years_b_c/]one million years b c[/url] terri movie http://moviestrawberry.com/films/film_shallow_ground/ ratatouile movie
hitman movie [url=http://moviestrawberry.com/films/film_blood_car/]blood car[/url] movie star in movie sex
auburn movie theaters [url=http://moviestrawberry.com/films/film_the_jungle_book_2/]the jungle book 2[/url] download the house of the spirits movie http://moviestrawberry.com/films/film_tapeheads/ the birds movie 60532
grumpy old men and movie quotes and mps and wav [url=http://moviestrawberry.com/films/film_ygi_duel_monsters_hikari_no_pyramid/]ygi duel monsters hikari no pyramid[/url] free japan sex movie http://moviestrawberry.com/easy-downloads/letter_A/?page=1 dog fuck free movie video downloads

Anonymous said...

downloadable movie maker software [url=http://moviestrawberry.com/films/film_bringing_up_bobby/]bringing up bobby[/url] free lesbian foot fetish movie http://moviestrawberry.com/films/film_gingerdead_man_2_passion_of_the_crust/ rockaway mall movie theaters
free download for movie serendipity [url=http://moviestrawberry.com/films/film_men_of_war/]men of war[/url] jane barbara good manners movie http://moviestrawberry.com/hqmoviesbygenres/download-genre_thriller-movies/?page=21 movie berkeley
loradonna porn movie [url=http://moviestrawberry.com/films/film_soylent_green/]soylent green[/url] norma rae movie
braintree amc movie theatre ma [url=http://moviestrawberry.com/films/film_the_crow/]the crow[/url] free porm movie clips http://moviestrawberry.com/films/film_in_which_we_serve/ love camp 7 movie
diphallia movie gallery [url=http://moviestrawberry.com/films/film_the_russell_girl/]the russell girl[/url] tsavo lion movie http://moviestrawberry.com/hqmoviesbygenres/download-genre_family-movies/?page=3 liscense to drive movie

Anonymous said...

flash electronic music press kit [url=http://mp3-s.co.uk/all_music-perpetua-featuring-kyara-17539-1/]Perpetua featuring Kyara[/url] serge cote music http://mp3-s.co.uk/all_music-taz-33-1/ ya ya and music
pearl jam music lyrics better man [url=http://mp3-s.co.uk/all_music-inner-glory-36062-1/]Inner Glory[/url] free christmas music radio online http://mp3-s.co.uk/all_music-ming-22-1/ rip music from dvm
amazing grace quartet sheet music for strings [url=http://mp3-s.co.uk/all_music-liane-foly-20768-1/]Liane Foly[/url] japanese music for koto
spiderman music [url=http://mp3-s.co.uk/all_music-terrence-fixmer-55145-1/]Terrence Fixmer[/url] soda sterio music http://mp3-s.co.uk/all_music-orgone-5-1/ genesis music and lyrics book
music stash [url=http://mp3-s.co.uk/all_music-bi-face-107180-1/]Bi-Face[/url] north tahoe music festival http://mp3-s.co.uk/all_music-suburban-base-29-1/ babe mason music

Anonymous said...

Male Enhancement reviews throw you an thought us, not only one small-scale constituent
of us pun intended. It literally immobilizes me, and plunk for yearner,
which should do wonders for you and your spouse's joy and expiation. Herbal twist problems tablets are one of the if you are earnest.
Here is my blog post ... homepage

Anonymous said...

Someone who commences employing one of these
courses wish the male enhancement will set out with the possible action workouts, travel care Sildenafil citrate nevertheless does a good deal
more than. Gains of 1 to 3 inches, with beginning results is for you to settle.
My web page ... penis advantage

Anonymous said...

E-cigarettеѕ don't have tobacco, but rather have a sort of vaporized nicotine.

my web page - V2 Cigs Coupon code

Anonymous said...

We would suggest stopping by the helpful web site for additional data.


Feel free to surf to my web site ... The Flex Belt Reviews

Anonymous said...

Increasingly people are adopting this technique which they're locating very very simple to practice.

my website http://justpostarticles.Com

Anonymous said...

The sixty day complimentary trial present is a wonderful
selection, in the case of the flex waistband.

my web blog ... flex Belt discount

Anonymous said...

The sixty day complimentary trial supply is a wonderful
choice, in the case of the flex waistband.

Feel free to surf to my web site Flex belt review

Anonymous said...

There is completely no hassle; there are no other factors to do aside from
putting it around your waist.

Here is my web-site: http://social.uppermovement.stuffsupresale.com/

Anonymous said...

The belt works to tighten your muscle tissues by contracting them, and then relaxing them,
and then repeating the motion, and it targets all the muscle
tissues in your abdominal section.

Also visit my website: Http://Www.Linkvis.Com/Profile/Ingrid437

Anonymous said...

The state of the art flex belt, attempt it you
will not regret it.

Look into my website :: The Flex Belt Review

Anonymous said...

For a lot more Informations Please check out our Overview site.



Also visit my homepage: Flex Belt review

Anonymous said...

There is definitely no hassle; there are no other issues to do aside from placing it around your waist.


Also visit my blog post; Www.articledirectorynews.com

Anonymous said...

Anyone who is willing to get a well-toned stomach can use
this belt.

Also visit my web blog - Http://Issuearticle.Com/Article.Php?Id=20307

Anonymous said...

There is absolutely no hassle; there are no other things to do aside from putting it about your waist.


Feel free to visit my blog post: www.towardssikkim.com

Anonymous said...

Not just that, you can indulge in further operates although
wearing this.

Feel free to surf to my site just Click the following webpage

Anonymous said...

In that respect, this item does work or at the pretty least does
not make untrue claims.

Also visit my site - Flex Belt

Anonymous said...

The belt utilizes gel pads postioned over the center abdominals and the
outside obliques.

my web blog - Flex Belt Coupon

Anonymous said...

The belt functions to tighten your muscle tissues by contracting
them, and then relaxing them, and then repeating the motion, and it targets all the muscles
in your abdominal section.

Here is my web page ... queeniesdiving.Com

Anonymous said...

Every single participant observed added benefits all through the review.


my blog post :: Flex Belt discount

Anonymous said...

You do not have to invest hours at the gym or exert so considerably effort and energy
in carrying out function out just to be capable to tone your muscle tissues.


Here is my web page ... Gunforglory.In

Anonymous said...

In simple fact, you never will need to go to your car
or truck vendor to have an oil adjust. Scroll menu and obtain out
the command button and examine the codes.

Here is my webpage - obdii scanner

Anonymous said...

This is one of the two most critical ideas. Pores and skin moles are typically harmless nevertheless,
at times it can be cancerous.

My homepage; dermatend mole remover