Journal of Bone and Soft Tissue Tumors (JBST) License
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Journal of Bone and Soft Tissue Tumors (JBST) is the official Journal of The Indian Musculo Skeletal Oncology Society
Factors Predicting Massive Blood Loss in Patients Undergoing Pelvic Resection: A Tertiary Referral Center Experience from North India
Original Article | Volume 6 | Issue 1 | JBST January-April 2020 | Page 5-8 | DOI: 10.13107/jbst.2020.v06i01.006
Author: Devansh Goyal [1], Venkatesan Sampath Kumar [1], Roshan Banjara [1], Abdul Majeed [1],
R Namith [1], Shah Alam Khan [1]
1. Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India.
Address of Correspondence
Dr. Venkatesan Sampath Kumar,
Department of Orthopaedics, All India Institute of Medical
Sciences, Ansari Nagar, New Delhi – 110 029, India.
E-mail: venkatortho4@gmail.com
Abstract
Background: Pelvic resections are challenging procedures with significant risk of morbidity, especially massive blood loss. Risk factors for massive blood loss are understudied due to the rarity of such procedures.
Materials and Methods: A cross-sectional study was performed on pelvic resections performed between January 2018 and October 2019. Intraoperative and perioperative data were collected from prospectively collected database and hospital medical records. Patients were divided into two groups– Group 1 with intraoperative blood loss <2 L and Group 2 with blood loss 2 L or more. Demographic data, tumor characteristics, surgical procedure, and perioperative outcomes were studied between the two groups. Patients in whom only soft-tissue resections were performed and those who did not have complete data were excluded from the study.
Results: Of the 27 patients identified, 2 had soft-tissue recurrence resections only and 4 had incomplete data and were excluded from the study. Of the remaining 21 patients, 8 were classified into Group 1 and 13 into Group 2. On studying the various characteristics, tumor type, tumor volume, type of pelvic resection, and duration of procedure were significantly different between the two groups. Although wound complications, 30-day mortality, and read missions were higher in Group 2, this difference was not statistically significant.
Conclusion: Massive blood loss was more common in chondrosarcoma patients, with tumor volume more than 300 cc and the duration of procedure more than 4 h with resection involving the acetabulum and pubis (Type I/II/III and Type I/II/III/IV).
Keywords: Blood loss, Pelvic resections, Perioperative morbidity, Pelvic tumor surgery, Tumor volume.
References
1. AbuduA, GrimerRJ, CannonSR, CarterSR, SneathRS. Reconstruction of the hemipelvis after the excision of malignant tumours. Complications and functional outcome of prostheses.J Bone Joint Surg Br1997;79:773-9.
2. WurtzLD, PeabodyTD, SimonMA. Delay in the diagnosis and treatment of primary bone sarcoma of the pelvis.J Bone Joint Surg Am1999;81:317- 25.
3. CarterSR, EastwoodDM, GrimerRJ, SneathRS. Hindquarter amputation for tumours of the musculoskeletal system.J Bone Joint Surg Br1990;72:490-3.
4. EnnekingWF, DunhamWK. Resection and reconstruction for primary neoplasms involving the innominate bone.J Bone Joint Surg Am1978;60:731-46.
5. KawaiA, KadotaH, YamaguchiU, MorimotoY, OzakiT, BeppuY. Blood loss and transfusion associated with musculoskeletal tumor surgery.J Surg Oncol2005;92:52-8.
6. SatcherRL Jr., O’DonnellRJ, JohnstonJO. Reconstruction of the pelvis after resection of tumors about the acetabulum.Clin OrthopRelat Res2003;409:209-17.
7. GutierrezG, ReinesHD, Wulf-GutierrezME. Clinical review: Hemorrhagic shock.Crit Care2004;8:373-81.
8. EnnekingWF, SpanierSS, GoodmanMA. A system for the surgical staging of musculoskeletal sarcoma.Clin OrthopRelat Res1980;153:106- 20.
9. AliAlgadiem E, AleisaAA, AlsubaieHI, BuhlaiqahNR, AlgadeebJB, AlsneiniHA. Blood loss estimation using gauze visual analogue.Trauma Mon2016;21:e34131.
10. GöbelV, JürgensH, EtspülerG, KemperdickH, JungblutRM, StienenU, et al. Prognostic significance of tumor volume in localized Ewing’s sarcoma o f b o n e i n c h i l d r e n a n d a d o l e s c e n t s . J C a n c e r R e s C l i n
Oncol1987;113:187-91.
11. RiedelRF, LarrierN, DoddL, KirschD, MartinezS, BrigmanBE. The clinical management of chondrosarcoma.Curr Treat Options Oncol2009;10:94-106.
12. TangX, GuoW, YangR, TangS, JiT. Evaluation of blood loss during limb salvage surgery for pelvic tumours.Int Orthop2009;33:751-6.
13. AljassirF, BeadelGP, TurcotteRE, GriffinAM, BellRS, WunderJS, et al. Outcome after pelvic sarcoma resection reconstructed with saddle prosthesis.Clin OrthopRelat Res2005;438:36-41.
14. BeneveniaJ, CyranFP, BiermannJS, PattersonFR, LeesonMC. Treatment of advanced metastatic lesions of the acetabulum using the saddle prosthesis.Clin OrthopRelat Res2004;426:23-31.
15. VenaVE, HsuJ, RosierRN, O’KeefeRJ. Pelvic reconstruction for severe periacetabular metastatic disease.Clin OrthopRelat Res1999;362:171-80.
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Unicameral Bone Cyst
Vol 5 | Issue 3 | September – December 2019 | page: 8-12| Vineet Kurisunkal, Manish Pruthi, Ashish Gulia. 10.13107/jbst.2019.v05i03.017
Author: Vineet Kurisunkal[1], Manish Pruthi[2], Ashish Gulia[3]
[1]M.S. Ortho, Fellowship in Musculoskeletal Oncology (HBNI)
Senior Clinical Fellow, Royal Orthopaedic Hospital, Birmingham, United Kingdom
[2]M.S. Ortho, DNB Ortho, Fellowship in Musculoskeletal Oncology (HBNI)
Consultant Orthopaedic Oncology, Rajiv Gandhi Cancer Institute, New Delhi
[3]M.S. Ortho, McH Surgical Oncology
Professor, Orthopaedic Oncology, Dept. Of Surgical Oncology
Tata Memorial Hospital, HBNI, Mumbai
Address of Correspondence
Dr. Ashish Gulia
Tata Memorial Centre, Homi Bhabha National Institute, Dr. E Borges Road, Parel, Mumbai – 400 012, India.
Abstract
Introduction:
Unicameral bone cyst (UBC) is a benign cystic lesion of the bone also known as simple bone cyst or solitary bone cyst. It was first recognized by Virchow in 1876. (1) Although exact incidence is not known, UBC’s accounts for 3% of all bone tumors with a male to female ratio of 2:1(2). Proximal humerus and proximal femur are the two most common sites for occurrence and accounts for approximately 80% of cases. Most of the UBC’s are recognized in age between 9 to 13 years, and the lesions usually heal by skeletal maturity. They are unilocular, serous or sero-sanguineous fluid filled bone cavity usually seen in metaphyseal region of long bones. It was originally recognized by Virchow in 1876 and subsequently studied in detail by Jaffe and Lichtenstein in 1942 (1)
Etiopathogenesis:
The etiopathogenesis of UBC is still very unsure, several theories have been postulated namely (3)
1. Virchow’s theory: Hypothesized the occurrence due to abnormalities in the local circulation of the affected area of bone.
2. Jaffe and Lichtenstein theory: Cystic cavity develops secondary to a traumatic insult leading to change in local circulation.
3. Mirra theory: On electron microscopy lesions appeared like intraosseous synovial cysts
4. Cohen’s theory: Hypothesized that the cyst forms as a response to venous occlusion in the intramedullary space.
5. Histopathologically: The lining of cavity contains synovial cells. On further evaluation of the cyst fluid high levels of oxygen free radicals and prostaglandins (prostaglandin E2, interleukin-1 and proteolytic enzymes) were found which have inherent ability to increase bone resorption hence create a cystic intramedullary cavity.
Epidemiology & Clinical features:
UBCs are lesions which arise in first two decades of life (85%) with 50% of lesions being detected in first decade itself and are rare to occur beyond age of 20 years. These Lesions show strong male predominance with male to female ratio of 2:1. (2) About 90% of cases occur in the proximal humerus, proximal femur and proximal tibia out of which most common location is the humerus (55% cases). Other less common sites are the ilium, distal humerus, tibia, calcaneum, talus, radius, ulna, and ribs. (4)
Patients are usually asymptomatic. Most lesions are picked up incidentally on plain radiographs when the patient presents following a history of fall or trauma or sport related injury. Few children present with pain after strenuous work or sports injury. (5)
Radiological Description:
UBC appears as a large, localized lytic lesion in the epimetaphyseal region of long bones. It appears expansile with a narrow zone of transition and a clear matrix. The adjacent matrix appears thinned with a well contained lesion. (6) A loculated appearance is due to the presence of ridges over the inner surface of the cyst rather than bony partitions, but following the healing of a fracture fibro osseous septa may actually form. Occasionally, a fragment of the fractured cyst wall is found in the fluid cavity which gives appearance to the pathognomic ‘fallen leaf sign”. (7) The cystic cavity may appear partially ossified or have septations after fracture or treatment. Mixed lytic sclerotic areas may be present in relapse cases.
Rarely magnetic resonance imaging may be warranted which reveals a single well contained lytic lesion with central fluid collection in primary cases. In the presence of previous healed pathological fractures across the cyst leads to formation of fibroosseous septations giving the appearance of an aneursymal bone cyst showing multiple fluid fluid levels. (8)
Histopathological Description:
Gross examination:
Fusiform expansion of the bone is noted with a classical description of being “egg shell” thin, semi translucent, bluish, and easily penetrable. (5) The cavity is a single lined cavity containing yellow fluid often appearing serosanguinous to hemorrhagic if there is associated history of trauma. Following a healed fracture, the cavity may become divided by fibro osseous septa. A thin layer of grey connective tissue lines the inner surface of the cyst wall, which displays multiple scroll like ridges that account for the pseudoloculated appearance on roentgenograms. (8)
Microscopy:
The cortical wall is composed of loosely trabeculated osseous tissue, and many thin walled vessels. The connective tissue is composed of layers of flattened cells (fibroblasts) lying on vascular collagenous or myxomatous tissue containing multinucleated giant cells, foam cells containing hemosiderin and lipids. (9) Following a fracture, periosteal new bone apposition may be evident. Recent literature reviews have revealed a number of new markers and histone mutations for differentiating benign from malignant tumours ie: Histone 3 mutations like H3F3A which is specific for giant cell tumours and H3F3B which is specific for chondroblastomas, these mutations help in differentiating from other giant cell containing tumours. (10)
Differential Diagnosis for UBC:
Varied benign and inflammatory bone lesion often lead to a misdiagnosis of unicameral bone cyst (5, 6) e.g.: Aneurysmal Bone Cyst (ABC), Fibrous Dysplasia with cystic changes, Enchondroma, Eosinphilic granuloma
ABC’s are eccentrically located lesions occurring near the metadiaphysis. Radiologically ABC’s show a significant expansion of the cortex, unlike the mild concentric expansion was seen in UBCs and show multiple fluid fluid levels which is pathognomic for ABC’s
Fibrous dysplasias are centrally located in the metadiaphyseal area occurring within the same age distribution. Radiographically lesion is usually “ground-glass” density.
An enchondroma has less sclerotic margins than the unicameral bone cyst and often contains a chondroid matrix and are usually located in the short tubular bones of the hands and feet.
Eosinphilic granuloma frequently involves axial skeleton than appendicular skeleton. Spinal Colum involvement is mostly seen in children. These are most destructive lytic lesion with associated soft tissue component and vertebral fracture or vertebra plana.
Treatment of UBC:
UBC’s are treated based on their stage at diagnosis. UBC’s could be latent or active, if a UBC has been diagnosed during its latent stage its most likely to be an incidental pick up which can be observed closely and should be followed up clinico – radiologically till healing. If during the observation phase there is an increase in the size or symptoms, it implies that lesion should be in the active stage of the disease and this should be intervened and treated. (6)
Treatment approach depends on the stage of UBC at presentation. Goal of treatment in UBC is to regain cortical thickness, bone strength and achieve healing of cyst. (3,11) If a lesion presents with a pathological fracture through the upper limb and is minimally displaced should be splinted and closely observed, there are studies which show cases spontaneously heal without any surgical intervention, the remaining cases have to be surgically stabilized. (4)
In lower limb defects, the treatment approach aims at aggressive surgical intervention so as to prevent any untoward event like occurrence of a pathological fracture. In a meta-analysis of 3217 cysts, healing after conservative treatment was 65% (27-100%). (3) In another study by Traub et al, healing after a conservative treatment was 70%. (12) However, in the study by Neer et al, healing of cysts after a conservative treatment was very low (4%) and was statistically low from healing after surgical procedures (77%) (p<0.001). (13) Also, subsequent fractures, growth disturbances and deformity were more common in the conservative treatment group.
In the meta-analysis of 62 studies (3217 cysts) mentioned earlier, the pool estimate of bone marrow injections was similar to steroid injections, 77.9% (65.9-89.9%). (3) The healing rates were improved when demineralized bone matrix was added. Healing rates after curettage were 90% while treatment with Intramedullary nails had almost 100% healing rates for UBC’s of long bones.
Based on the published literature, various treatment options have been suggested for the treatment of UBC’s. These can be broadly divided into 2 categories – (4, 8, 11, and 14)
a) Percutaneous interventions:
i. Percutaneous aspiration of the cyst fluid and steroid injection – When a corticosteroid is injected into a unicameral bone cyst, the cyst will heal in most cases by new bone formation.
Method: This is done by two needle method. Needles are introduced into the cavity to allow free escape of cystic fluid. Removal of fluid should be thorough so that the injected suspension of prednisolone acetate crystals can cover the whole cyst wall cavity. Up to 200 mg can be injected depending up on the size of the cavity. Generally, repeat injections are required. The injection does not appear to impair the growth of the epiphyseal plate, and no biochemical disturbances have been noted. Commercially available bone substitute material can be injected in to the cavity to provide osteogenic potential and rapid healing.
ii. Percutaneous aspiration of the cyst fluid and autogenous bone-marrow injection.
iii. Percutaneous aspiration of the cyst fluid and demineralized bone matrix injection
iv. Percutaneous aspiration of the cyst fluid and demineralized bone matrix combined with bone-
marrow injection.
v. Percutaneous drilling and Kirschner wires, Cannulated screws, or flexible intramedullary nails insertion to provide continuous decompression of the cyst.
b) Surgical procedures:
Principles of surgical intervention in a case of UBC’s:
i. The fracture should be allowed to heal with splinting if required maintaining limb length
ii. Adequate sized bone window should be made for curettage
iii. The reduce recurrence cyst wall cavity should be completely excised
iv. Avoid damaging the growth plate in order to avoid angular deformities
v. Cavity may be filled with bone grafts or bone graft substitutes
vi. Periosteum should be preserved for inducing osteogenesis
vii. Recurrent lesions may require subperiosteal resection
Described surgical techniques are:
i. Limited Curettage and bone grafting: This is the classical method of curettage where a small bony window is made and curettage is attempted through this cavity. This method is associated with a high rate of local recurrence due to inadequate disease clearance
ii. Extended intralesional curettage and bone grafting: Extended curettage is done by making an adequately sized bony window and post curettage all intervening bony septae and cyst membrane are broken down using a high-speed burr. The residual cavity is reconstructed using auto or allografts.
iii. Partial Resection and Bone Grafts: Subtotal excision of the cavity is done leaving only a small longitudinal portion of host bone to maintain length and stability. A strut of auto/allograft or in combination with morsellized bone graft can be used to fill the defect. The preserved periosteum is closed over the grafts.
Complications:
• Immediate Complications:
i. Pathological Fractures
ii. Angular Deformities
iii. Limb Length Discrepancy
• They are also associated with increased chance of local recurrence which ranges from 10 to as high as 80 percent
References
1) Sung AD, Anderson ME, Zurakowski D, Hornicek FJ, Gebhardt MC. Unicameral bone cyst: a retrospective study of three surgical treatments. Clin Orthop Relat Res. 2008;466(10):2519-26.
2) Kaelin, Andre & D. MacEwen, G. (1989). Unicameral bone cysts. International Orthopaedics. 13. 275-282. 10.1007/BF00268511.
3) Kadhim, M., Thacker, M., Kadhim, A., & Holmes, L. (2014). Treatment of unicameral bone cyst: systematic review and meta analysis. Journal of children’s orthopaedics, 8(2), 171-91.
4) Ulici, A., Balanescu, R., Topor, L., & Barbu, M. (2012). The modern treatment of the simple bone cysts. Journal of medicine and life, 5(4), 469-73.
5) Evans J, Blake J. Unicameral Bone Cyst. [Updated 2019 Feb 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470587/
6) Noordin, S., Allana, S., Umer, M., Jamil, M., Hilal, K., & Uddin, N. (2018). Unicameral bone cysts: Current concepts. Annals of medicine and surgery (2012), 34, 43-49. doi:10.1016/j.amsu.2018.06.005
7) S. Struhl, M.D., C. Edelson, M.D., H. Pritzker, M.D., L.P. Seimon, M.D., and H.D. Dorfman, M.D. Solitary (unicameral) bone cyst The fallen fragment sign revisited. Skeletal Radiology (1989) 18:261-265
8) Donaldson, S., Chundamala, J., Yandow, S., & Wright, J. G. (2010). Treatment for unicameral bone cysts in long bones: an evidence based review. Orthopedic reviews, 2(1), e13.
9) Aiba, Hisaki & Kobayashi, Masaaki & Waguri-Nagaya, Yuko & Goto, Hideyuki & Mizutani, Jun & Yamada, Satoshi & Okamoto, Hideki & Nozaki, Masahiro & Mitsui, Hiroto & Miwa, Shinji & Kobayashi, Makoto & Endo, Kojiro & Saito, Shiro & Goto, Taeko & Otsuka, Takanobu. (2018). Treatment of aneurysmal bone cysts using endoscopic curettage. BMC Musculoskeletal Disorders. 19. 10.1186/s12891-018-2176-6.
10) Cleven, Arjen & Höcker, Saskia & Bruijn, Inge & Szuhai, Karoly & Cleton-Jansen, Anne-Marie & Bovee, Judith. (2015). Mutation Analysis of H3F3A and H3F3B as a Diagnostic Tool for Giant Cell Tumor of Bone and Chondroblastoma. The American journal of surgical pathology. 39. 1576-1583. 10.1097/PAS.0000000000000512.
11) Kadhim, Muayad & Sethi, Samir & M. Thacker, Mihir. (2016). Unicameral Bone Cysts in the Humerus: Treatment Outcomes. Journal of Pediatric Orthopaedics. 36. 392-399.
12) Traub, Frank & Eberhardt, Oliver & F. Fernandez, Fransico & Wirth, Thomas. (2016). Solitary bone cyst: A comparison of treatment options with special reference to their long-term outcome. BMC Musculoskeletal Disorders. 17. 10.1186/s12891-016-1012-0.
13) Alshryda, Sattar & Wright, James. (2017). Evidence-Based Treatment of Simple Bone Cyst. 10.1007/978-3-319-41142-2_43.
14) Fauzi Kamal, A., A. Ajiantoro, and Y. Prabowo. “Simple Bone Cyst Treated With Percutaneous Steroid Injection”. Asian Journal of Pharmaceutical and Clinical Research, Vol. 11, no. 5, May 2018, pp. 186-90, doi:10.22159/ajpcr.2018.v11i5.21775.
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Editorial September – December 2019
Editorial | Volume 6 | Issue 1 | JBST September – December 2019 | Page 21 | Yogesh Panchwagh, Ashish Gulia, Ashok Shyam. 10.13107/jbst.2019.v05i03.014
Author: Dr. Yogesh Panchwagh[1], Dr. Ashish Gulia[2] & Dr. Ashok Shyam[3],[4]
[1]Orthopaedic Oncology Clinic, Pune, India.
[2]Orthopedic Oncology Services, Department of Surgical Oncology,
Tata Memorial Hospital, Mumbai.
[3]Indian Orthopaedic Research Group, Thane, India
[4]Sancheti Institute for Orthopaedics &Rehabilitation, Pune, India
Address of Correspondence
Dr. Yogesh Panchwagh.
Orthopaedic Oncology Clinic, 101, Vasant plot 29, Bharat Kunj
Society -2, Erandwana, Pune – 38, India.
Email: drpanchwagh@gmail.com
JBST has completed 5 years of publication. At present, JBST is indexed with Index Copernicus, ETH Bibliothek and Google scholar while the process of Pubmed indexation is in pipeline. Being the official journal of the Indian Musculoskeletal Oncology Society (IMSOS), most of the contributions to the journal have come from the members of IMSOS. There have been respectable international contributions too, mostly in form of review articles. We have noticed that the original research articles which JBST would like to emphasize on currently, are far and few to be submitted. We feel one of the main reason for this could be the pending pubmed indexation.
The awareness about need of publications is already there in the subcontinent. We believe that there is tremendous clinical work ongoing. The data analysis and writing of the manuscripts, which earlier was in the backseat, also is on the rise currently. Most of the educational institutes now look at the research done and published by the faculty to decide on multitude of factors like enhancing financial aid, giving additional manpower and deciding on appraisals and promotions. This boosts the need of doing more research and publishing it.
When an author thinks of sending his or her original research work to a journal, the main thing that plays a role is the indexation. It simply is a reflection on how the journal is valued, how much of a difference it’s making in the concerned field and whether the processes followed are up to a certain standard. This in turn gives a certain credibility to the journal. However, there were certain branches, orthopaedic oncology being one, where there was dearth of a journal dedicated to the field. JBST aimed at filling the void and giving an option to the researchers to publish their hard work which otherwise takes a long time to find its way to the online or print version of journals dedicated to a broader speciality. Our focus was and always will be quick turnaround time, good quality and being clinician and researcher friendly. Considering that most clinicians and students would have limited budget allocation, we have kept the publishing fees to the bare minimum. In fact, for the life members of the affiliated societies of the journal, JBST is happy to waive off the publishing fees.
As we continue to walk the path that we had set our feet on, we would like to thank all our authors, reviewers, editorial board members and readers for the pivotal role that they have played over the years in shaping JBST. With continued help and support by the above mentioned, we hope to continue improving and getting better.
Dr. Yogesh Panchwagh
Dr. Ashish Gulia
Dr. Ashok Shyam
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Is Jungle Scout Really Worth? – Customer Reviews
Are you are planning to sell on Amazon? Then the most important factor you will think about is “How to find profitable products on Amazon?” Here is the solution! Instead of spending so many hours doing the product research, just use the smart jungle scout tools to do your product research in 10 mins. Jungle Scout is the most reliable and must-try tool to earn a pocket full of dollars on Amazon.
Jungle Scout comes in two different products, web apps and Chrome extensions which helps to filter amazon product categories and choose your own criteria of products. Find amazing discounts from time to time from us as sometimes we get exclusive deals to promote from Jungle Scout without partnership.
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There is no other group with leadership, intelligence, work ethic, and discipline than someone who has served in the United States military. My father served for more than 20 years in the military, and I have seen those skills translate directly to a successful business career.
The FBA charges change as per the item, so to keep a net revenue on the exchange, the merchants must remember what they are offering and the amount they are offering it for. When they comprehend the sales, they can incorporate the stock of profitable items and furthermore lookout for competitors’ performance. A standout amongst the best ways by which dealers can recognize the best items to offer on Amazon is through Jungle Scout.
Is Jungle Scout Really Worth?
Jungle Scout is a wonderful time-saving tool with a great interface. The fact that it overlays the data on top of the existing browser page, makes it super quick and easy to search and track products on Amazon. It also captures and highlights the information for all variations of a product, when performing research.
On the downside, the Product Database may provide a great source of ideas, but it doesn’t cover everything that’s listed on Amazon. You may have to do your own manual researches to find something interesting and add them to your Product Tracker. Also, the sales estimate isn’t always accurate. You would need to keep a watch on the product through the tracker to get a better idea.
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PhenQ – Weight Loss Pills Reviews & Results
Getting slim, losing weight, taking exercise and going on dieting seems to be a daunting task for most of the people who have put on a lot of weight. Though Genetics also play a huge role in our body structure and the shape of our core areas, things we can control are how much exercise we engage in and what we put in our bodies on daily basis. Our body is a complex machine that continuously works for us to live.
When you use cheap junk food as fuel, you get fatty and non-muscular as a result. It is similar to a vehicle in that matter. When you use unleaded 87 gas as compared to unleaded 92 gas, the same principle applies. The higher premium gas takes care of a vehicle better. This also applies to food and nutritional supplements that we take.
Unhealthy food and inferior quality supplements that are intended to cause weight loss, may be of poor quality and not able to do the job as the manufacturer marketed the medicine. One must be careful about what diet pills they take. That is why it’s important to read online reviews on products before you make a choice. After seeing many stellar reviews, this was found consistently to be a supplement product of high quality. Users consistently got the desired results they were hoping to achieve. This Phenq reviews 2019 answers all the questions that you might have about this product.
What Is PhenQ?
PhenQ is supplied and manufactured by WOLFSON BERG LIMITED. This company states they are proud of leading the supplements industry for over a decade. PhenQ is described as a weight loss pill that puts emphasis on many facets of weight loss and not just a typical appetite suppressant. They’re also proud of having helped over 190,000 customers!
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DOES PHENQ WORK?
Yes, PhenQ really works. I too was a bit skeptical before using it, but I am very glad I ended up purchasing the 3 month supply. You should also know that the ingredients found in this product have been studied and tested extensively. Take a look at the results from the clinical studies. The formula will help you burn more calories throughout the day. Burn more calories, lose more weight. So in case you’ve been wondering.
Does Really PhenQ Work?
The fact that this product has over 190,000 satisfied customers and that it’s backed by science should answer your question. PhenQ works great when it comes to burning fat and suppressing appetite. However, it isn’t a magic pill. You will still need to diet and exercise.
But it’s going to help a lot throughout the process. For me, it made a major difference. Controlling my appetite was a real problem for me and this is where PhenQ made a huge difference. On the official website, you’ll find plenty of more people that have shared their results.
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Welcome to Taco Bell Survey & Feedback
People remember the days when they used to have paper reviews and surveys everywhere. People used to follow the traditional paper feedback methods in which we will be getting paper after our visit to any store. People even feel irritated when they were asked to do the paper surveys for a long time like 15-20 minutes. Most of the people don’t even show any kind of interest to take part in surveys. Then some people came with a creative solution and they are nothing but Online Surveys. Here we came up with a new topic called official tellthebell feedback and survey and its importance to customers.
The best thing in those online surveys is they can be completed in less time, even more, flexible as they will be in an easier format than compared to conventional paper surveys. Then every company started utilizing those surveys and have been following their outcomes. Taco bell a famous fast food restaurant chain that is an American origin is not an exception in this.
The publication’s annual fast food survey, released Wednesday, found giants like McDonald’s, KFC, Burger King, and Taco Bell all lagging behind their newer, hipper fast-casual counterparts, like In-N-Out Burger and Chipotle.
“After devouring 96,208 meals at 65 chains, Consumer Reports readers told us that quality of the food has become more important in their dining decisions, and convenience of location is less so,” the Consumer Reports release on the study read. “They could be reasons the traditional fast-food chains are losing their edge: Diners, especially younger adults in the millennial generation, maybe more willing to go out of their way to get a tasty meal.”
Taco Bell is an American chain of fast-food restaurants and is a California origin, also a subsidiary of Yum! Brands, Inc. These restaurants serve a variety of Tex-Mex(Texas-Mexican) foods that include tacos, burritos, quesadillas, nachos, novelty, and specialty items. Glenn Bell is the founder of Taco Bell Restaurant who is behind the success of the company.
They have started more than 7000+ stores all around the world from its origin in 1962. That figures can simply show how a successful brand TacoBell is and how it is growing day by day. And for such a large firm there is a tremendous requirement to know the feedback of their customers. Then in such a niche space, they started availing the services of tellthebell.com where people can give feedback on their visit to the TacoBell store.
The survey is conducted to know what the customers think about the food and services provided by Taco Bell, what their needs are. So, be honest and give your genuine feedback and accurate information as much as possible during the survey. It will be extremely helpful to assess the company’s performance and give the best experience for the diners.
Eligibility to enter the survey and the drawing
To join the survey, participants need to fulfill some requirements. You can also check the official sweepstakes rules by clicking the link at the bottom of the survey page.
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