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Transobturator crossover readjustable sling for severe female incontinence: Technique and preliminary results buy generic baclofen 25 mg on line spasms near heart. Spiral sling salvage anti-incontinence surgery in female patients with a nonfunctional urethra: Technique and initial results buy cheap baclofen 25 mg muscle relaxant that starts with a t. Surgical treatment of stress urinary incontinence using a method for postoperative adjustment of sling tension (Remeex System) discount baclofen 25 mg visa spasms gallbladder. Cabestrillo de tension regulable “Remeex” en el tratamiento de la incontinencia urinaria femenina: Tecnica quirurgica personal purchase baclofen 25 mg without a prescription spasms near ovary. Sousa-Escandon, Cabrera J, Mantovani F, Moretti M, Ionadis E, Kondelidis N, Neyemeyer J, Noguera R. Adjustable suburethral sling (male remeex system) in the treatment of male stress urinary incontinence: A multicentric European study. A re-adjustable sling for female recurrent stress incontinence and sphincteric deficiency: Outcomes and complications in 125 patients using the remeex sling system. The degree of heating and the physical effects vary according to the frequency and wavelength of the electromagnetic energy as well as the duration of exposure. High-frequency electromagnetic energy (radio frequency) is the basis for radio transmissions, while very high (microwave) levels are used in radar or, more familiarly, in microwave ovens. Light at high frequencies and wavelengths, as produced by lasers, can also have a rapid heating effect of its target. Application of radio frequency, microwave, or laser energy results in excitation of water molecules and rapid heating of biologic fluids and tissue, with subsequent tissue remodeling or destruction. The controlled application of electromagnetic energy at radio frequency and microwave frequency levels has been widely used to treat a spectrum of medical conditions. High levels of radio frequency, as in electrocautery, are commonly used for hemostasis [4]. Application of high-energy radio frequency is also widely used for the thermal destruction (ablation) of arrhythmic cardiac tissue [5], shrinkage of excessive soft palate tissue [6], shortening of injured spine and joint ligaments [7,8], shrinkage of joint cartilage [9], reduction of liver tumors [10], and reduction of benign hyperplastic prostatic tissue [11,12]. Such procedures utilize relatively high levels of radio frequency energy to heat body tissues to the point of necrosis, which results in gross tissue shrinkage. In contrast, the application of lower levels of radio frequency energy generates lower tissue temperatures (65°C–75°C). Instead, application of controlled, low-level radio frequency energy results in acute, focal collagen denaturation (Figure 77. After healing, the denatured collagen results in reduced dynamic compliance of the surrounding untreated tissue without stricture formation. Lower levels of radio frequency energy have successfully been used to treat conditions such as fecal incontinence (e. The vaginal mucosa is dissected off the underlying endopelvic fascia to expose the surface area for treatment. Subsequently, a transvaginal probe is used to apply high-energy radio frequency to heat and shrink the underlying tissues [16,17]. Radio frequency energy is delivered until blanching or charring of the tissues is noted. Similar energy is applied on both sides of the proximal urethra, always maintaining position 1 cm lateral to the urethra. The goal of this procedure is to shrink the endopelvic fascia, thereby increasing support for the bladder neck [16]. In an early study of the procedure performed laparoscopically in 94 women (mean age, 48. Urodynamic evaluation showed no leakage during the Valsalva maneuver in 78% of patients. Further studies were unable to reproduce earlier successful results and high rates of additional treatments were required [18–20]. It was determined that transvaginal radio frequency ablation is too dependent on precise technique, and it is no longer marketed [21]. Viable, denatured submucosal collagen stains bright blue and small vessels are undamaged. This procedure differs in several ways from transvaginal radio frequency bladder neck suspension. Unlike the high- energy transvaginal radio frequency procedure, transurethral radio frequency collagen denaturation is applied through four small needle electrodes and does not require surgical incisions. Additionally, in high-energy radio frequency ablation, target tissue is heated to produce tissue necrosis followed by gross shrinkage of the endopelvic fascia [16,17,22]. In contrast, transurethral radio frequency causes collagen denaturation and does not produce tissue necrosis, resulting in a functional (reduction in tissue compliance) rather than an anatomic change. Initial animal studies of transurethral collagen denaturation of the bladder neck and proximal urethra evaluated its gross and histologic impact, and physiologic effect demonstrated its feasibility and safety, suggesting a beneficial effect [23]. The tiny submucosal sphere of denatured collagen (circle) deep in the unaffected mucosa is only identified by chronic inflammatory cells clustered on its superior border. It is not meant to replace existing treatment options, but to complement the spectrum of available treatments. Additionally, patients who experience suboptimal primary surgical results may benefit from transurethral radio frequency collagen denaturation. Women who have undergone a surgical procedure and experience residual or recurrent incontinence must be carefully evaluated before considering further treatment options. The feasibility, safety, and comfort of using oral instead of intravenous sedation were demonstrated in two prospective trials [24,25]. In a study by Lenihan and colleagues, the first six patients received an oral sedative plus an oral analgesic, as well as a local periurethral anesthetic block using 2% lidocaine. Postoperatively, patients classified their pain on a visual analog scale from 0 (“no pain”) to 10 (“terrible pain”) [24]. This in- office anesthetic regimen using oral sedation allowed for treatment completion in all patients without the need to convert to intravenous sedation (100% feasibility). Technique A prophylactic oral antibiotic is administered, and the patient may opt to receive an oral sedative. Once the patient is placed in the low lithotomy position, she is given a periurethral lidocaine block (Figure 77. The bladder is drained with a urinary catheter, after which 30 cc of sterile, room-temperature water is instilled into the bladder and the catheter is removed. The balloon at the probe tip is then insufflated and the device gently withdrawn until the balloon is anchored palpably within the bladder neck, at which time the length of the urethra is measured. During treatment, four 23-gauge nickel titanium needle electrodes are then deployed from the probe shaft immediately distal to the balloon, traversing the mucosa and positioning the tips within the submucosa of the bladder neck and proximal 1 cm of the urethra (Figure 77. The submucosa immediately surrounding the four needle tips is heated and maintained at 65°C for a minimum of 30 seconds, resulting in microscopic, focal collagen denaturation without substantial tissue necrosis. The probe is repositioned after each treatment cycle, and the cycle is performed nine times, using simple deployment and rotational maneuvers, resulting in collagen denaturation of 36 circumferential, microscopic focal sites within the bladder neck and proximal urethral submucosa.

The objective has been to provide enough of a “feel” for the subject so that the probabilistic aspects of statistical inference can be more readily understood and appreciated when this topic is presented later proven 25mg baclofen muscle relaxant neck. We defined probability as a number between 0 and 1 that measures the likelihood of the occurrence of some event purchase baclofen 25mg without a prescription spasms diaphragm. Objective probability can be categorized further as classical or relative frequency probability buy baclofen 10mg line quad spasms after acl surgery. After stating the three properties of probability baclofen 10mg for sale muscle relaxant powder, we defined and illustrated the calculation of the following kinds of probabilities: marginal, joint, and conditional. We also learned how to apply the addition and multiplication rules to find certain probabilities. We learned the meaning of independent, mutually exclusive, and complementary events. We learned the meaning of specificity, sensitivity, predictive value positive, and predictive value negative as applied to a screening test or disease symptom. Finally, we learned how to use Bayes’s theorem to calculate the probability that a subject has a disease, given that the subject has a positive screening test result (or has the symptom of interest). Define the following: (a) Probability (b) Objective probability (c) Subjective probability (d) Classical probability (e) The relative frequency concept of probability (f) Mutually exclusive events (g) Independence (h) Marginal probability (i) Joint probability (j) Conditional probability (k) The addition rule (l) The multiplication rule (m) Complementary events (n) False positive (o) False negative (p) Sensitivity (q) Specificity (r) Predictive value positive (s) Predictive value negative (t) Bayes’s theorem 2. The study used data from the Behavioral Risk Factor Surveillance System surveys of adults age 18 years or older conducted in 1999 and 2000. The table below reports the number of observations of Hispanic and non-Hispanic women who had received a mammogram in the past 2 years cross-classified with marital status. Wilson, “Breast and Cervical Cancer Screening Practices Among Hispanic and Non-Hispanic Women Residing Near the United States–Mexico Border, 1999–2000,” Family and Community Health, 26 (2003), 130–139. The table below shows the skill retention numbers in regard to overall competence as assessed by video ratings done by two video evaluators. The researchers classified subjects into four personality types: obsessiod, asthenic=low self-confident, asthenic=high self-confident, nervous=tense, and undeterminable. A certain county health department has received 25 applications for an opening that exists for a public health nurse. If a selection from among these 25 applicants is made at random, what is the probability that a person over 30 or a person with a master’s degree will be selected? Made a low score on the examination given that he or she graduated from a superior high school. For a variety of reasons, self-reported disease outcomes are frequently used without verification in epidemiologic research. They used the self-reported cancer data from a California Teachers Study and validated the cancer cases by using the California Cancer Registry data. The following table reports their findings for breast cancer: Cancer Reported (A) Cancer in Registry (B) Cancer Not in Registry Total Yes 2991 2244 5235 No 112 115849 115961 Total 3103 118093 121196 Source: Arti Parikh-Patel, Mark Allen, William E. Wright, and the California Teachers Study Steering Committee, “Validation of Self-reported Cancers in the California Teachers Study,” American Journal of Epidemiology, 157 (2003), 539–545. In a certain population the probability that a randomly selected subject will have been exposed to a certain allergen and experience a reaction to the allergen is. If a subject is selected at random from this population, what is the probability that he or she will have been exposed to the allergen? Suppose that 3 percent of the people in a population of adults have attempted suicide. It is also known that 20 percent of the population are living below the poverty level. In a certain population of women 4 percent have had breast cancer, 20 percent are smokers, and 3 percent are smokers and have had breast cancer. The probability that a person selected at random from a population will exhibit the classic symptom of a certain disease is. For a certain population we define the following events for mother’s age at time of giving birth: A ¼ under 20 years; B ¼ 20–24 years; C ¼ 25–29 years; D ¼ 30–44 years. For a certain population we define the following events with respect to plasma lipoprotein levels (mg=dl): A ¼ (10–15); B ¼ð! State in words the meaning of the following events: (a) A [ B (b) A B (c) A C (d) A [ C 20. Since they show all possible values of a random variable and the probabilities associated with these values, probability distributions may be summarized in ways that enable researchers to easily make objective deci- sions based on samples drawn from the populations that the distributions represent. This chapter introduces frequently used discrete and continuous probability distributions that are used in later chapters to make statistical inferences. We build on these concepts in the present chapter and explore ways of calculating the probability of an event under somewhat more complex conditions. In this chapter we shall see that the relationship between the values of a random variable and the probabilities of their occurrence may be summarized by means of a device called a probability distribution. A probability distribution may be expressed in the form of a table, graph, or formula. Knowledge of the probability distribution of a random variable provides the clinician and researcher with a powerful tool for summarizing and describing a set of data and for reaching conclusions about a population of data on the basis of a sample of data drawn from the population. The purpose of the study was to examine hunger rates of families with children in a local Head Start program in Athens, Ohio. In addition, participants were asked how many food assistance programs they had used in the last 12 months. We wish to construct the probability distribution of the discrete variable X, where X ¼ number of food assistance programs used by the study subjects. We compute the probabilities for these values by dividing their respective frequencies by the total, 297. These are not phenomena peculiar to this particular example, but are characteristics of all probability distributions of discrete variables. With its probability distribution available to us, we can make probability statements regarding the random variable X. Solution: To answer this question, we use the addition rule for mutually exclusive events. The cumulative probability distribution for the discrete variable whose probability distribution is given in Table 4. The length of each vertical line represents the same probability as that of the corresponding line in Figure 4. Solution: Since a family that used fewer than four programs used either one, two, or three programs, the answer is the cumulative probability for 3. Solution: To find the answer we make use of the concept of complementary probabili- ties. The set of families that used five or more programs is the complement of the set of families that used fewer than five (that is, four or fewer) programs. In later sections, we study in detail three of these theoretical probability distributions: the binomial, the Poisson, and the normal. Mean and Variance of Discrete Probability Distributions The mean and variance of a discrete probability distribution can easily be found using the formulae below. Solution: m ¼ð1Þð:2088Þþð2Þð:1582Þþð3Þð:1313ÞþÁÁÁþð8Þð:0370Þ¼3:5589 2 2 2 2 s ¼ð1 À 3:5589Þ ð:2088Þþð2 À 3:5589Þ ð:1582Þþð3 À 3:5589Þ ð:1313Þ 2 þÁÁÁþð8 À 3:5589Þ ð:0370Þ¼3:8559 We therefore can conclude that the mean number of programspffiffiffiffiffiffiffiffiffiffiffiffiffiffiutilized was 3.

The base of the lower same time the vermilion is lifted and any perioral wrinkles are triangle is larger than the base of the central upper triangle buy baclofen 10 mg without prescription spasms spinal cord. Start the infiltration process to obtain analgesia and Similar results can be obtained with the ‘lip lift’ where the haemostasis order baclofen 25 mg line muscle relaxant reversals. The incisions are made along the lines that mark the sides In 1991 generic 10 mg baclofen with visa spasms 1983 dvd, writing about the ‘corner lift’ discount baclofen 10mg on-line muscle relaxant in elderly, Austin describes the of the triangles and at the level of the vermilion, along the resection of a triangle of skin carried out above and laterally to lateral and external lines, stopping a few millimetres from the commissure of the lip. The results seem to be cut through the full thickness of the mucosa down to the stable and the scar of good quality, located in the end part of the muscular layer. The dissection, directly above the muscular lip contour prolonged toward the exterior (Fig. Austin and Weston managed to confine the scar to the commis- The dissection at the level of the transition line must always sure, involving, however the whole corner of the lip. Any, even if reduced, possibility of dehis- cence or hypotrophy could have serious consequences (Fig. The correction The closure of the V in Y indicates the extent of the advancement and of the length of the upper lip confers a significant, at times therefore the increase in the surface of the vermilion which is everted gaudy aesthetic improvement of the face, immediately per- ceptible after the operation and permanent. Moreover, the The tissue structure of the labial commissures is very contour is also improved and appears less flat, due to lift- delicate and thus placing a scar, for aesthetic ends, in a ing, and an augmentation of the vermilion, due to eversion corner which is often humid and mobile must be evaluated (Fig. It may be a specular image of the upper placing of the cutting line is essential for the quality of the line if no change to the shape of the lip is desired; an accen- scar which is usually invisible. The drawing is completed with three ver- The previously traced cutaneous ellipse is cut to the muscu- tical reference lines: a median line and two lateral ones lar layer and is separated from the muscular plane (Fig. These must be maintained thread starting with sutures at the median and lateral lines. The lower the line, the greater fectly adjoining skin margins may be sutured with a 6/0 mono- the effect on the increase of the vermilion and the aesthetics filament nylon thread to be removed on the fifth day (Fig. The exeresis of a 5–6 mm cutaneous ellipse is A thin layer of antibiotic cream is applied and the wound is left Cheiloplastics 1063 a b c Fig. No warned so that they are not disappointed in the post- antibiotic therapy is required. The local oedema, usually of minor importance, migrates The indication of the lip lift i s the reduction of the long gravitationally towards the vermilion augmenting its lip, not increased volume which may just be an associated volume, a fact usually welcomed by patients who must be feature (Figs. Corrective aesthetic interventions more often than not aim at • The results become satisfactory only after the acute the reduction in volume, as in hyperplasia of genetic origin, oedema period, which lasts some days, and in the lip, irre- most common in people of black African origin. The last spective of the correction undertaken, the swelling is decade has seen an increased demand for reductive surgical always significant due to its rich vascularization and interventions of an iatrogenous origin due to the increased mobility. The patient must cially during mouth movement, but this abates within a be aware of the fact that insufficient reduction may be revised few days. It is essential to have precise and stable reference points • The operation will necessarily leave scars. The permanent that aim at a symmetrical result, irrespective of the extent of scars on the skin depend on the type of correction and are the reduction. That is the purpose of tracing the median line not perceivable as they are well camouflaged by their which goes from the contour to the frenulum and the transi- location, but their evolution also depends on the skin type tion line ; they will serve as a reference in programming the and in the third month after the operation may appear quantity of the excess tissue to be resected. They must be hypertrophic and will stabilize around the sixth month perpendicular to each other at the end of the operation. This phenom- The suture is carried out with a rapidly re-absorbing enon is rare in the scars in the vermilion and the mucosa. As in all operations complications may arise, such as The consensus form is a document where the patient declares oedemas, sieromas and infections. After having carefully read and discussed each unclear term entific context guaranteeing complete anonymity with the surgeon, the patient signs the form as a confirmation. The different surgical corrective procedures used are not covered by a single general consent form. Information rela- tive to all procedures to be communicated to the patient fol- 10. Alka Seltzer, Ascritptin, Aspirin, Bufferin, Cemerit, Vivin • The operation will take place in the surgery under local C) or other non-steroid anti-inflammatory drugs. Scott published the first reports using Botulinum toxin joined by a disulfide bond to a 50-kDa light chain. When the type A for the treatment of blepharospasm, strabismus, and heavy chain attaches to the proteins on the surface of axon glabellar frown lines in the early 1980s. It is a sterile, homogenous, lyophilized complex rarely, F and G are associated with human botulism [4]. Multiple factors including molecular weight, protein size, serotype strain, and prepara- genetics, photoaging, smoking, underlying disease, gravity, tion/purification process. These factors determine their onset and muscular hypertrophy affect our appearance and facial of action, longevity of effect, and migration to the surround- expressions as time goes by. No systemic spread or anaphylactic reactions have The Horizontal Forehead Lines been reported, however. The prod- • Lateral fibers of the orbicularis oculi muscle uct should be administered within 24 h of being • Neck bands: platysma reconstituted. The patients procerus, corrugator supercilii, and orbicularis oculi should be informed about the possible minimal side effects muscles). Other Function of the primary smile muscle, the zygomaticus important factors to consider are the patient’s occupation and major, results in the elevation of lateral upper lip diago- physiological and aesthetic differences between men and nally with actions of laughing, smiling, and chewing. Relative contraindications are tion produces synergistic effects in the periorbital region, patients with of neuromuscular transmission disorders (e. If the patient’s current medical history includes use of This muscle is in part an antagonist to the lip elevators. Eyelid ptosis responds well to alpha-adrenergic agonist eye drops phenylephrine (Neo-synephrine 2. Remember that Neo- synephrine is contraindicated in patients with narrow angle glaucoma. These mydriatic agents work via stimulating Muller’s muscle and elevate the upper eyelid, restoring it to its normal position (Fig. While talking with the patient, we can easily notice pain levels in sensitive patients as well as to reduce the risk various patterns of facial animation and other features such of bruising and swelling, patients may use an ice pack or as brow asymmetry. Small subcutaneous wheals applied to the injection sites for sterility but should be fully of 0. Attention is then turned to corrugator function on the Post procedure, patients are given ice packs and asked not brow; here it is helpful to palpate the muscle while the patient to engage in vigorous physical activity for 24 h to prevent is contracting. Both the lateral canthal injections and inferomedial brow injections can be expected to “open up” the aperture of the eye. It has proven useful both as a primary treatment for certain facial 10 Specific Considerations: Glabellar rhytids and as adjunctive agent for a variety of facial aes- Frown Lines thetic procedures to obtain optimal results.

For example order baclofen 25 mg visa spasms during meditation, during a chole- Placement) cystectomy the monitor should be positioned on the patient’s right side in direct line of vision of the surgeon baclofen 10 mg with amex muscle relaxant id. While during a laparoscopic Nissen the surgeon stands between the legs of the patient in the French position with the monitor placed at the head of the patient facing the surgeon baclofen 25 mg free shipping muscle relaxant zanaflex. To fx a height discrepancy between the surgeon and the table order baclofen 10 mg amex spasms while high, one should either readjust the table or use steps. If the problem is not fxed with adjustment of the table, the ports are placed too high and need to be repositioned to a lower location. For example, during a laparoscopic appendectomy, tilting the table right side up and head down helps to move the small bowel into the left upper quadrant for better exposure. Trocar Placement and Triangulation Successful laparoscopic suturing is dependent on a key concept in laparoscopic surgery, the triangulation of instruments. Triangulation occurs when the right and left hands of the surgeon are positioned on either side of the camera and form a 90° angle with the camera. This is the basic trocar position and will avoid the “knitting needle” effect of the instruments when using a two-handed technique. In addition to the triangulation of trocars at the skin at ninety degrees with the laparoscope, it is important to insert the trocar in such a way that the instruments also triangulate inside the abdomen at ninety degrees in a double triangulation (Fig. This is critical and especially impor- tant in patients who are morbidly obese with a thick abdominal wall. A trocar that is inserted straight down does not allow any movements of the instruments. C camera port; A left hand; B right hand, moved laterally The intra-abdominal triangulation prevents the instruments from aligning them- selves parallel to each other, which would make the task of suturing very diffcult. Another common problem encountered in port placement is when a trocar is placed too medially and too close to the camera port. In this situation, instead of only visualizing the tip of the instrument in the feld, the shaft is partially in line with the camera and will obstruct the view; this is known as the “shaft sign” (Fig. The solution is to move the trocar by partially removing it and then sliding the skin with the help of the trocar more laterally before reinserting it. The ideal ergonomic position for the camera is when the laparoscope is in line with the target while preserving the double triangulation. Equipment Designated advanced laparoscopic equipment is necessary to perform advanced proce- dures. This equipment includes additional specifcations for the purposes of laparo- scopic suturing. Needle nose grasper for the receiving and supporting hand is shown here Needle Holders Appropriate needle-holders are necessary, at least for the surgeon’s dominant hand. The ideal needle-holder has a long shaft, a straight handle that allows some rotation of the wrist, and jaws with a diamond shape that will grasp the needle appropriately. The trig- ger mechanism of the needle-holder should be comfortable, and the jaws should grasp frmly enough without use of excessive force, which may crush and break the suture. The needle-holder should be single action without any exposed hinges in which the suture material can be caught (Fig. The only grasper with a ratchet is used to retract the gallbladder during a cholecystectomy. It is important to avoid graspers with exposed hinges in laparoscopic Intracorporeal Knot-Tying 269 surgery, because the suture can become caught in the hinge during laparoscopic knot- tying. Most double action graspers are double-hinged; hence the author recommends use of single action grasper (needle nose grasper). The nondominant, supporting hand of the surgeon should ideally hold long, atraumatic, single-hinged forceps with jaws, without groove marks that would entrap the suture (Fig. Suture Material Suture material choice is similar as in open surgery, however the rule is to use one “0” thicker than would be used in open surgery. Hence, 2–0 sutures should be used for the various muscular and fascial closures, and 3–0 sutures reserved for fne suturing such as on the esophagus, stomach or colon. Shorter sutures will render the technique of intra and extracorporeal knot-tying more diffcult and a frustrating struggle will ensue. Interrupted Stitch Intracorporeal Knot­Tying The scrub technician prepares the thread by removing the memory and cutting the thread at the appropriate length: 14 cm for one interrupted stitch, 24 cm for a running stitch. The thread is grasped at least 5 mm from the needle and then the needle is intro- duced through the 10 mm port. This prevents the future confusion of having a needle inside the abdominal cavity in case the needle count is incorrect. As in open surgery, the needle is grasped one-third of the distance from the inser- tion of the thread to the tip. The movements of the hands should be natural, with the needle at 90° to the shaft of the needle-holder. The left hand grasps the tissue and pres- ents it to the needle-holder as in open surgery, and usually once the needle has passed the frst layer, it can be grabbed with the left hand and presented to the empty needle- holder again before entering the second, opposite layer. In other words, the thread should create an inverted “C” with the loop facing upwards (Fig. With the loose end on the right side of the surgeon, the surgeon rotates the needle-holder (pronation of the wrist), advances the needle- holder on top of the grasper, rotates the needle-holder (supination of the wrist), and pulls the needle-holder back, all while the grasper remains unmoving. The tip of the grasper is then opened; the suture is grasped and pulled through to complete the knot. The opposite maneuver is made when the loose end is on the left side of the surgeon 270 Chapter 16  Advanced Laparoscopic Suturing Techniques Fig. It is also important that the tips of the needle-holder and the grasper do not touch each other, as it will decrease the speed of suturing. In summary, intracorporeal knotting resembles open microsurgical instrumental knot-tying. In the case of a surgeon who is left handed, the initial steps and the frst square knot are achieved in the reverse position. Running Stitch Tying an intracorporeal knot after a running stitch follows the same principles as an interrupted stitch. To retrieve the needle once the knot has been tied, the thread should be held very close to needle and gently pulled out through the port. If no thread remains, align the needle with the needle-holder and pull the needle out under direct vision of the camera. In this maneuver, the thread is grasped and used to pirouette the needle into place (Fig. Once the needle is in the correct alignment, it can be simply grasped by the needle-holder if needed. This avoids the often clumsy, time consuming transfer of the needle between instruments, further dulling the needle and deforming the shape.

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