erythema nodosum lupus

alright, “systemic lupus erythematosus,”k we totally got this. “systemic” is easy, and refers to affecting multiple organs inthe body. “erythematosus” means reddening of the skin, alright alright. “lupus”is latin for “wolf”. so affects multiple organs wolf...reddening of the skin? not exactly,the modern use of lupus usually refers to a variety of diseases that affect the skin...whichwas possibly originally used since these diseases resemble a wolf bite on the patients’ skin.is that true? who knows. at any rate, systemic lupus erythematosus, or sle, sometimes justlupus, is a disease that’s systemic, and affects a wide variety of organs, but notablyoften causes red lesions on the skin. but how does lupus affect all these organs?well usually the immune system protects the

body’s tissues from invaders, but lupusis an autoimmune disease, which means that immune cells start attacking the very tissuestheir supposed to protect. with lupus, essentially any tissue or organ can be targeted. and justlike a ton of other autoimmune diseases though, it’s not completely clear why it develops,and like most diseases it’s the result of both genetics and the environment. alright so let’s go over a specific scenarioto show how this plays out. let’s say this guy has susceptibility genes—genes thatmake him susceptible to getting lupus, and he’s exposed to uv radiation in sunlight,which we know is an environmental risk factor for lupus. well, given enough uv rays, thinklike sunburn, the cell’s dna can become

so badly damaged, that the cell undergoesprogrammed cell death, or apoptosis, and it dies. this produces all these little apoptoticbodies, and exposes the insides of the cell, including parts of the nucleus, like dna,histones, and other proteins, to the rest of the body. well those susceptibility genesspecifically have an effect on this person’s immune system such that their immune cellsare more likely to think that these are foreign, or antigens, and since they’re from thenucleus, we call them nuclear antigens, and immune cells try to attack them. not onlythat though, susceptibility genes also cause this person to have less effective clearance,essentially they aren’t as good at getting rid of the apoptotic bodies and so they endup having more nuclear antigens floating around.

this means that b cells might swing by, seethem, and start the production of antibodies against these pieces of nucleus, which arecalled antinuclear antibodies, and these guys are present in almost all cases of lupus.alright so those antinuclear antibodies bind to the nuclear antigens, forming antigen-antibodycomplexes. these complexes can get into the blood and then drift away and deposit or stickto the vessel wall in all sorts of different organs and tissues like the kidneys, skin,joints, heart. deposited complexes then initiate a local inflammatory reaction, which causesdamage through the activation of the complement system, which, after a huge cascade of enzymeactivation, leaves cell membranes with channels that let fluid and molecules go in and outall willy nilly, causing the cell to burst

and die, usually though you’d want thisto happen to foreign cell or an infected cell, not healthy cells. when tissues become damagedas a result of these immune complexes, it’s known as a type iii hypersensitivity reaction.uv radiation isn’t the only way to damage cells, though, right? it therefore isn’tthe only trigger that’s thought to be associated with lupus—other potential triggers thathave been associated with sle include cigarette smoking, viruses, bacteria, use of certainmedications like procainamide, hydralazine, and isoniazid, as well as sex hormones, particularlyestrogen, which might be partly why lupus is more common in women, especially consideringit’s about 10 times more common in women than men during reproductive years, but onlyabout 2 or 3 times more common in childhood

or past the age of 65. okay okay, as a quick recap, the model that’sgenerally thought to be what leads to sle starts with some environmental trigger, whichdamages cells, and causes apoptosis and the release of nuclear antigens. at this point,the genetic components come in, and the person likely has certain genes that make them notso good at clearing these apoptotic bodies and nuclear antigens, so you end up with alot of nuclear antigens floating around. in combination, they probably also have genesthat cause their immune cells to recognize these nuclear antigens as foreign, which initiatesan immune response, creates antinuclear antibodies that bind to antigens and then float aroundand deposit in various tissues, which causes

inflammation. these deposits and inflammation seem to bethe cause of most of the symptoms of lupus, which remember is a type iii hypersensitivityreaction. many patients, though, also develop antibodies targeting other cells like redand white blood cells, and molecules like various phospholipids, which can mark themfor phagocytosis and destruction, leading to additional symptoms. this is considereda type ii hypersensitivity reaction, although it isn’t fully understood why some of theseantibodies targeting specific cells and molecules develop. so the classic presentation of lupus is fever,joint pain, and a rash in a woman of childbearing

age, but the actual diagnosis is difficultbecause it can affect a variety of people of different genders and ages, and there’realso a wide variety of symptoms. there are general symptoms like fever and weight loss,as well as specific symptoms depending on the specific organ system being affected anddamaged. in fact, it’s so unpredictable that a diagnosis is given only when 4 or moreout of eleven diagnostic criteria are met. the first few have to do with the skin andoften happen to sun-exposed areas; the first is a malar rash, meaning a rash over the cheeksthat spares the nasolabial folds, sometimes just called a “butterfly rash” and thisappears after sun exposure. second is a discoid rash, which is chronic rash in sun-exposedareas that are plaque-like or forms a sort

of patchy redness and can scar. finally, ageneral photosensitivity of the skin—essentially a catch-all category for other rashes thathappen to sun-exposed areas—typically only lasting a couple of days. another type of tissue that can be damagedis the mucosa, or the the inner membrane of various tissues can become damaged as well,so the fourth criteria is ulcers in the mucus membrane of the mouth or the nose. lupus canalso affect the serosa, which is like the outer membrane of an organ or tissue, so ifit gets inflamed, people get get serositis, which could manifest as something like pleuritis,which is inflammation of the lining around the lungs and chest cavity, or as pericarditis,inflammation of the lining of the heart. although

this isn’t strictly a criteria, it’s worthnoting that lupus can affect any layer of the heart—meaning in addition to inflammationof the pericardium, they might also have inflammation of the endocardium and myocardium, leadingto endocarditis and myocarditis, of which the former presents as libman-sacks endocarditis,where vegetations form, which are essentially clumps of fibrin, a blood-clotting proteinand immune cells, around the mitral valve. next, if the joints get inflamed, patientsmay also develop arthritis, specifically two or more joints to meet the criteria. if thekidneys are affected, patients might develop renal disorders, like abnormal amounts ofurine protein or diffuse proliferative glomerulonephritis, inflammation of the glomeruli. for reasonsthat aren’t completely understood, some

autoantibodies that target receptors in thebrain have been implicated as well, and this can cause neurologic disorders like seizuresand psychosis. sort of along the same lines, patients can have autoantibodies against componentsof the blood, causing various hematologic disorders, for example they’ll get anemiaif red blood cells are targeted, thrombocytopenia if platelets are targeted, and leukopeniaif white blood cells or immune cells are targeted. that last one is really a mind-bender becauseit means that your immune system is attacking your immune system. alright so the last twohave to do with specific antibodies being found in the blood, the first one being antinuclearantibody, which we already went through. now a large proportion of patients with lupushave these, meaning this test is very sensitive,

but this test isn’t very specific, sincethese are seen in other autoimmune diseases. finally, they can have some other self-directedantibody that isn’t antinuclear antibody, which can be one of three types. it couldbe anti-smith, which is an antibody against small ribonucleoproteins, or it could be anti-dsdnawhich is against double stranded dna and is often seen more during periods of active disease.these two are relatively specific for lupus. a third type of antibody though is anti-phospholipidwhich is actually against proteins that are bound to the phospholipids, and is less specificfor lupus, meaning that it can pop up in other situations. there are three types of antiphospholipidantibodies - anticardiolipin, which can cause a false-positive test for syphilis since anticardiolipinantibodies are also sometimes involved in

syphilis, the other two are lupus anticoagulantalso known as lupus antibody, and anti-beta2 glycoprotein i. sometimes, because of these,patients with lupus develop an antiphospholipid syndrome, where the antiphospholipid antibodiescause a hypercoagulable state, meaning they’re more prone to developing clots and havingcomplications like deep vein thrombosis, hepatic vein thrombosis, and stroke. these patientsoften end up needing lifelong anticoagulation therapy. so lupus is characterized by periods of flare-upsand periods of remittance, so treatment is often aimed at preventing flares or limitinghow severe they are when they do happen. to help prevent flares, some patients may haveto avoid sunlight exposure with hats and long-sleeved

clothes. to reduce severity of flares, corticosteroidsmay be used to help limit the immune response, and finally, if symptoms are really severe,certain immunosuppressive drugs might be used.

pictures of lupus

hey this is dr k from imedicalschool and todaywe are going to talk about systemic lupus erythematosis otherwise known as sle. so as the name suggests sle is a systemicautoimmune disorder that causes inflammation and affects all the major organs of the body.if you are interested in learning what you can do to help further lupus research or supportadvocacy for lupus patients make sure to check out the lupus foundation of america at lupus.org. since lupus is a systemic inflammatory disorderwhat are the symptoms of lupus? well lupus commonly presents with a multitude of generalizedsymptoms making the differential diagnoses quite broad. some common general symptomsinclude fever, fatigue, myalgias, arthritis,

and weight loss. there are additional symptomsand signs associated with lupus and we will talk about them next as we discuss how todiagnoses lupus. the most important step in understanding anydisease is grasping how to diagnose the disease. lets talk about how to diagnose lupus. thereare many pneumonics that can aid in remembering all the diagnostic criteria. the one i rememberis called dopamine rash. you need to have at least 4 criteria met to diagnose lupus. lets go through each one. the d representsdiscoid rash. a discoid rash is a disc shaped rash that is flat but has pronounced rednessat the borders. here we have a picture that demonstrates a discoid rash.

next we have oral ulcers. generally patientswill have ulcers that you find incidentally on exam. the way to differentiate these ulcersfrom infectious ulcers is that infectious ulcers are usually painful while ulcers fromlupus are generally painless. other skin findings include a photosensitiverash. photosensitive means that sun exposure triggers and can worsen the skin rash. patientsdo not need much sun exposure to really develop these rashes. in addition patients may experience jointpain otherwise known as arthralgia or joint inflammation known as arthritis. a classic physical exam finding for a lupuspatient is the malar rash. the malar rash

affects the cheeks and the bridge of the nose.in a truly classic rash it appears in the shape of a butterfly covering the nasal bridgeand both cheeks. in addition to rashes another criteria isimmunologic phenomenon. immunologic phenomenon include detection of anti-smooth muscle antibody,anti-double stranded dna, ant-ro and anti-la (otherwise known as ssa and ssb.) finallyif the lupus is drug induced you may see anti-histone antibodies. the next criteria are neurologic phenomenon.patient can develop altered mental status, seizures, stroke and headache. in additionto mental status changes lupus can damage the kidneys causing either a nephritic ora nephrotic disorder. nephritic disorder is

when the kidney is damaged causing proteinuriawith less than 3.5 g/day in the urine. in addition in a nephritic disorder a patientmay have high blood pressure and rbc casts. nephrotic disorder is when there is significantprotein loss of greater than 3.5 g/day in the urine. in addition patients have elevatedcholesterol levels, low albumin levels, and edema. one of the classical tests for lupusis ana or antinuclear antibody. ana is sensitive but not specific so a positive ana alone doesnot indicate lupus and you need to look for other criteria described by dopamine rashto make the diagnosis. other symptoms are characterized as serositis.this includes pleuritis, pericarditis, and peritonitis. finally patient can have hematologicalphenomenon. these include anemia, thrombocytopenia,

and hemolytic anemia. now that we have talkedabout the diagnostic criteria for lupus lets talk about how to monitor disease activity. lupus patient will need frequent routine labsto monitor disease activity. key labs include c3, c4, and ch50. these labs test the complementsystem. when lupus is highly active it leads to consumption of complement factors. in additiona rise in the igg anti-double stranded dna indicates an increase in disease activity.in addition to monitoring disease activity, as we know, lupus can cause kidney damage.one indicator of proliferative glomerulonephritis is a drop in c1q complement. the next importantstep is treatment of lupus one of the most important factors in decreasingdisease activity is to stop smoking. smoking

has been linked to worsening disease activityand worse outcomes. like i mentioned before lupus patients should be monitored with frequentlabs. these labs include cbc, esr, crp, urinalysis, spot urine and creatinine, ch50, c3, c4, andanti double stranded dna. in terms of actual therapy the first step is to begin with nsaids.if nsaids do not control symptoms, and they rarely do, hydroxychloroquine can be used.hydroxychloroquine is an antimalarial medication and has been shown to prevent damage to thecentral nervous system and kidneys. if symptoms continue to persist and major organs are beingaffected systemic corticosteroids should be administered. finally if these therapies donot work the patient needs to be escalated to methotrexate, cyclophosphamide, and azathioprinefor better system control.

well that was a brief review of systemic lupuserythematoisis. i hope you liked the video. if you did please share this video with yourfriends on facebook and twitter. give this video a like, place any comments or suggestionsdown below and most importantly subscribe. you can follow us on our facebook page imedicalschoolor twitter at imedschool finally check out our podcast on itunes under imedicalschool.this is dr k from imedicalschool and i will see you next time.

lupus profundus

systemic lupus erythematosus, abbreviatedas sle. this is a systemic disease, which means thatit can affect the whole body systemically. the brain, skin, heart, lungs, kidneys, joints,the immune system, the vascular system, and the list goes on. lupus means wolf. erythematosus means reddening of the skin. why did i show a red butterfly? because a very typical sign of sle is a butterflyshaped reddening of the skin. the way i remember this disease, is to imaginea wolf that attacks a woman, and why a woman?

because 9 out 10 patients are women. so the wolf bites the face of the woman causinga butterfly shaped erythema on her face. then the wolf continues to bite all her organsone by one, because this disease is a systemic disease, which means that it can affect allthe organs systemically. of course this disease has nothing to do witha wolf. but sle is an autoimmune disease, which meansthat this woman called emma have an immune system that attacks her own body, insteadof only attacking bacterias, viruses and parasites. so emma have an immune system that acts asa wolf inside her.

i will show you how we can find out if emmareally has sle by diagnosing her. and then we will look at what type of medicationswe can give her. i want you to remember at least one thingfrom this presentation. that is systemic lupus international collaboratingclinics, abbreviated as slicc. slicc is a criterion that can help in thediagnosis of sle. slicc contains clinical criteria, immunologiccriteria and biopsy criteria. we need more than 4 criteria with at least1 clinical and 1 immunologic. or we need 1 biopsy criteria and 1 immunologiccriteria.

so what does these 3 words mean? clinical, immunologic and biopsy? the synonym for clinic, is hospital. so clinical criteria stand for the symptoms,signs and lab values of a patient in the hospital. immunology deals with the immune system thatprotects you from bacterias, viruses, and immunologic criteria are usually lab teststhat detect any problem with the immune system. biopsy means that a doctor cuts out a pieceof an organ. for example, a small piece of kidney can becut out, and then the doctor puts this piece of kidney in a microscope and looks for diseases.

clinical criteria can be divided into alopecia,which means hairloss. skin problemsulcers heart diseaseslung diseases kidney problemsjoint pain problems with the nervous systemand blood diseases. skin problems can be grouped under the namecutaneous lupus erythematosus. we can divide these skin diseases into acutesubacute and chronic, based on the timing of the diseases. acute diseases are usually those that happensuddenly with a short duration.

chronic diseases are ongoing for a long time. whereas subacute means those diseases thatare not yet chronic but has passed the acute phase. a way to remember these timing are to memorize2 numbers. 1 and 3. why? because the duration of acute diseases areusually less than 1 month, subacute are 1 to 3 months, and chronic are more than 3 monthsin duration. so which are the acute type of skin problems?

butterfly erythema, which is a reddening ofthe face in a butterfly shape. it usually affects the cheeks or also calledmalar region, and therefore it is sometimes called malar erythema. it does not affect the nasolabial region. there can also be bullous lesions which areblisters that can be a mix of small grouped vesicles to large tense bullae. bullae are elevating the skin and are filledwith fluid. toxic epidermal necrolysis-like sle, is adetachment of the epidermis, the upperlayer of the skin, resulting in exfoliation, meaningthat the upperlayer just falls off.

this is very dangerous, because the skin isthe organ that protects against infections. so if you loose a large part of your skin,then sepsis can happen, which means that bacterias easily invade your vascular system, sincethere is no skin to protect you. this can lead to something called septic shock,which can lead to death. maculopapular rash is another acute sign. macules are flat spots up to 1 cm, and papulesare bumps up to 1 cm. maculopapular is a combination between maculesand papules. photosensitivity can also be seen which meansthat the skin is much more sensitive to sunlight than normally.

this can cause cause solar urticaria, whichis a vascular reaction of the skin that cause pathches. patches are flat lesions like macules, butthey are bigger than 1 cm. so one difference between macules and patchesis the size. macules are less than 1 cm, whereas patchesare more than 1 cm. so the acute cutaneous lupus erythematosuscan be divided into 5 lesions: butterfly shaped erythema, bullous lesions, toxic epidermalnecrolysis, maculopapular rashes, and photosensitive solar urticarias. subacute cutaneous lupus erythematosus canbe divided into 2 types.

one is annular polycyclic lesions. the word polycyclic refers to more than 1ring structures that can be seen in chemistry for example. the word annular also refers to a ring-shapedstructure. so annular polycyclic lesions are ring-shapedskin lesions that usually occur on sun-exposed areas of the skin. nonindurated psoriaform is the other typeof subacute skin lesions. psoriaform means that it looks like psoriasis. nonindurated means that it is not hardas psoriasis.

subacute can be divided into annular polycyclicand nonindurated psoriaform lesions chronic skin lesions are chilblain lupus,that affects toes, fingers, nose, and ears during cold weather. these are painful, bright red nodules. nodules means a swelling of the skin thatis up to 1 cm diameter. discoid rash can also be seen. discoid refers to the disc shape of theselesions. we can divide discoid into classical type. discoid lesions can be divided into localized,which means that discoid lesions appear above

the neck,and generalized, which means that discoid lesions can appear both above and below theneck. lichen planus is an inflammatory disease thatcan affect the skin and oral mucosa. here we see a picture of whitish lichen planuson the oral mucosa. the word lichen means tree-moss as you cansee here on the picture. so this disease is looking like a tree mossbut with a whitish color. in sle patients this happen, that a discoidlesion is seen together with lichen planus. verrucous lesions or also called hypertrophiclesions are skin that hypertrophies, which means that the skin cells increase in numberand cause these hard wartlike lesions, especially

on extensor arms. mucosal lesions can affect the mucosal membranearound the teeth, the tongue, and hardpalate panniculitis or also called profundus, isan inflammation and destruction of the subcutaneous fat. tumidus lesions are pinkish urticarial non-scarringplaques usually in sun-exposed areas. plaques are elevation of the skin similarto papule, but they differ in size. so plaques are more than 1 cm in diameter,whereas papules are less than 1 cm. the chronic skin lesion are chilblain, discoid,discoid with lichen planus, hypertrophic, mucosal, panniculitis, and tumidus.

ulcers can appear on the mucosal membrane,on for example the hardpalate, buccal region, on the tongue, and on the nasal septum. inflammation can affect the heart causingpericarditis. here we see a normal normal heart on the upperpicture, and a reddish heart on the lower picture. inflammation is causing redness, pain, heat,swelling and loss of function. the heart wall rub against each other causinga typical pericardial rub sound that one can hear with a stethoscope. here we see a man having a painful pericarditispericardial effusion can also happen, which

means that fluid accumulates around the heartcausing a typical waterbottle-shaped heart on x-ray. as i mentioned, pericardial rub sounds canbe heard with a stethoscope. inflammation can also affect the lungs. so similar to the heart, there will be inflammation,pain, pleural friction rub sounds, and pleural effusionhere we can see the pleural effusion that have accumulated between the 2 layers of thelungs. this is how pleural friction rub sounds like. imagine walking on snow when you hear thissound.

we need to collect urine to find kidney problems. more than 500 mg of protein in the urine duringa 24 hour period can be seen in sle patients. this is called proteinuria, meaning proteinin the urine, which is not normal. we can also find red blood cell casts in theurine by analyzing the urine in a microscope. these casts are formed by red blood cellsthat stick together. blood in the urine is not normal. it suggest that something is wrong with thekidney. synovitis is inflammation of the synovialmembrane of the joints. polyarthritis can be seen in sle.

poly stands for that more than 1 joint isaffected. arthritis is inflammation of joint. so more than 1 joint will be inflamed causingpain. the nervous system can also be affected bysle. seizures can happen, which are hyperexcitationof neurons in the brain, sometimes leading to muscle contractions. psychosis and acute confusional state, alsocalled delirium can happen. psychosis and delirium patients usually sufferfrom hallucinations. neuropathies can be seen in sle.

neuropathy means neurons that are diseased. the neurons can be in the cranial part, peripheralpart, in the spinal cord which is then called myelitis, or single nerves can be damagedwhich is then called mononeuropathy, mono standing for single. or multiple single nerves in different areasof the body can be damaged, which is then called multiple mononeuropathy. what can we see in the blood? with a microscope we can distinguish differentblood cells. here is a picture showing the blood cells.

the blood cells originate from one cell calledmultipotential hematopoetic stem cell. this cell can produce myeloid cells, and lymphoidcells. the myeloid cells can produce erythrocytes,also called red blood cells. but in sle hemolytic anemia can be seen, whichmeans that the erythrocytes can damaged and therefore anemia will happen, which meansthat not enough oxygen is transported to the tissues. the myeloid cells can also produce megakaryocytes,that can further produce thrombocytes, also called platelets. but in sle the number of thrombocytes canbe reduced, and we call this thrombocytopenia.

penia stands for less of something, inthis case we have a penia of thrombocytes, so thrombocytopenia. the symptom of thrombocytopenia is usuallypetechiae which are small purplish spots on the skin. leukopenia can happen in sle which is a reducednumber of leukocytes, which are white blood cells, with neutrophils being the most commonwhite blood cell. lymphopenia can also be seen, which are reducednumber of lymphocytes. so the clinical criteria were alopecia, skinlesions, ulcers, diseases of the heart, lungs, kidneys, joints, nervous system and the blood.

the immunologic criteria are related to autoantibodies,meaning that the antibodies of the immune system attacks itself, instead of only attackingbacterias etc. here we have a cell, with its nucleus, containingchromosomes that contain dna. in sle, the antibodies attack your own nuclearproteins, for example your own dna, or rna binding proteins called smith proteins. so in sle we check for antinuclear antibodylevels, abbreviated as ana. we also check anti-smith and anti-double strandeddna. another immunologic criteria is direct coombstest. here we mix the patients blood together witha coombs reagent, and if red blood cells agglutinate,

meaning they stick together, then we havea positive test result. the complement system helps or complementsthe antibodies to fight infections. in sle we can see a low number of these complementproteins. the complement proteins are numbered c1 toc9, and it is the c3 and c4 complement proteins that are low in sle. ch50 stands for the total complement activity,which is also low in sle. an increased number of antiphospholipid antibodiescan be measured in sle. these antibodies bind to proteins like beta2 glycoprotein 1 on the phospholipid cell membrane.

the function of the beta 2 glycoprotein 1is to prevent phospholipid membrane to activate the thrombosis cascade. we know that thrombosis can cause death. so therefore it is very important to checkthe antiphospolipid antibody level. it is especially important in pregnant women,because these antibodies can cause spontaneous abortion and late fetal death. except antiphospholipid antibodies, sle flarescan also cause fetal death. sle fluctuate between flares and remissions. a flare is a very active disease with manysymptoms, whereas a remission is an inactive

state with few symptoms. during pregnancy, the mother should be monitoredfor any sle flares since these can lead to fetal death. so if a woman wants a child, then pregnancyshould be timed for when sle is in remission for at least 6 months. furthermore, anti-ro antibodies should bemeasured, because if anti-ro is detected, then doctors should warn mothers that thereare risks of the fetus getting a neonatal lupus or even a severe congenital heart blockwhich means the death of the fetus. so it is very important to monitor the fetalheart in this case, with for example an echocardiograph

and a 24-hour holter monitor. lets turn now to the biopsy criteria. here we need a biopsy of the kidney, whichwill show that there is inflammation, called nephritis. but it is not enough with a biopsy, we needan immunologic criteria as well, for example antinuclear antibodies, or anti-double-strandeddna. now lets see how we can treat sle patients. the first thing that we have to do is to removeany type of medication that can cause sle-like symptoms.

these are for example hydralazine, procainamide,and isoniazid. non-steroidal anti-inflammatory drugs arevery useful in sle patients, especially in controling arthralgias, which means painfuljoints. here we can use naproxen, ibuprofen, and diclofenac. antimalarial medications also help jointsproblems, but also skin problems, and they reduces the sle flares. the typical sle medication is hydroxychloroquine,but there are alternative like chloroquine and quinacrine. hydroxychloroquine can in rare cases causeretinal problems, skeletal muscle problems

and cardiac problems. so it is important that the eyes are examinedyearly. corticosteroids are usually the first linetreatment in acute severe sle. we typically begin by giving intravenous methylprednisolonefor 3 days and then we maintain the therapy with prednisone. disease-modifying antirheumatic drugs arealso very important. we can use azathioprine, methotrexate, mycophenolatemofetil, cyclophosphamide together with mesna, and in very severe cases intravenous immunoglobulin. it is well known that corticosteroid use fora long time can cause osteoporosis, which

means bone weakening. therefore it is important to consider givingcalcium, vitamin d, and bisphosphonate. so to conclude, we can say that emma has sle,which is a systemic autoimmune disease, that affects her whole body systemically. the brain, skin, heart, lungs, kidneys, joints,the immune system, and the vascular system. the typical butterfly-shaped erythema canbe seen in sle patients. thank you very much for listening!

lupus panniculitis

systemic lupus erythematosus, abbreviatedas sle. this is a systemic disease, which means thatit can affect the whole body systemically. the brain, skin, heart, lungs, kidneys, joints,the immune system, the vascular system, and the list goes on. lupus means wolf. erythematosus means reddening of the skin. why did i show a red butterfly? because a very typical sign of sle is a butterflyshaped reddening of the skin. the way i remember this disease, is to imaginea wolf that attacks a woman, and why a woman?

because 9 out 10 patients are women. so the wolf bites the face of the woman causinga butterfly shaped erythema on her face. then the wolf continues to bite all her organsone by one, because this disease is a systemic disease, which means that it can affect allthe organs systemically. of course this disease has nothing to do witha wolf. but sle is an autoimmune disease, which meansthat this woman called emma have an immune system that attacks her own body, insteadof only attacking bacterias, viruses and parasites. so emma have an immune system that acts asa wolf inside her.

i will show you how we can find out if emmareally has sle by diagnosing her. and then we will look at what type of medicationswe can give her. i want you to remember at least one thingfrom this presentation. that is systemic lupus international collaboratingclinics, abbreviated as slicc. slicc is a criterion that can help in thediagnosis of sle. slicc contains clinical criteria, immunologiccriteria and biopsy criteria. we need more than 4 criteria with at least1 clinical and 1 immunologic. or we need 1 biopsy criteria and 1 immunologiccriteria.

so what does these 3 words mean? clinical, immunologic and biopsy? the synonym for clinic, is hospital. so clinical criteria stand for the symptoms,signs and lab values of a patient in the hospital. immunology deals with the immune system thatprotects you from bacterias, viruses, and immunologic criteria are usually lab teststhat detect any problem with the immune system. biopsy means that a doctor cuts out a pieceof an organ. for example, a small piece of kidney can becut out, and then the doctor puts this piece of kidney in a microscope and looks for diseases.

clinical criteria can be divided into alopecia,which means hairloss. skin problemsulcers heart diseaseslung diseases kidney problemsjoint pain problems with the nervous systemand blood diseases. skin problems can be grouped under the namecutaneous lupus erythematosus. we can divide these skin diseases into acutesubacute and chronic, based on the timing of the diseases. acute diseases are usually those that happensuddenly with a short duration.

chronic diseases are ongoing for a long time. whereas subacute means those diseases thatare not yet chronic but has passed the acute phase. a way to remember these timing are to memorize2 numbers. 1 and 3. why? because the duration of acute diseases areusually less than 1 month, subacute are 1 to 3 months, and chronic are more than 3 monthsin duration. so which are the acute type of skin problems?

butterfly erythema, which is a reddening ofthe face in a butterfly shape. it usually affects the cheeks or also calledmalar region, and therefore it is sometimes called malar erythema. it does not affect the nasolabial region. there can also be bullous lesions which areblisters that can be a mix of small grouped vesicles to large tense bullae. bullae are elevating the skin and are filledwith fluid. toxic epidermal necrolysis-like sle, is adetachment of the epidermis, the upperlayer of the skin, resulting in exfoliation, meaningthat the upperlayer just falls off.

this is very dangerous, because the skin isthe organ that protects against infections. so if you loose a large part of your skin,then sepsis can happen, which means that bacterias easily invade your vascular system, sincethere is no skin to protect you. this can lead to something called septic shock,which can lead to death. maculopapular rash is another acute sign. macules are flat spots up to 1 cm, and papulesare bumps up to 1 cm. maculopapular is a combination between maculesand papules. photosensitivity can also be seen which meansthat the skin is much more sensitive to sunlight than normally.

this can cause cause solar urticaria, whichis a vascular reaction of the skin that cause pathches. patches are flat lesions like macules, butthey are bigger than 1 cm. so one difference between macules and patchesis the size. macules are less than 1 cm, whereas patchesare more than 1 cm. so the acute cutaneous lupus erythematosuscan be divided into 5 lesions: butterfly shaped erythema, bullous lesions, toxic epidermalnecrolysis, maculopapular rashes, and photosensitive solar urticarias. subacute cutaneous lupus erythematosus canbe divided into 2 types.

one is annular polycyclic lesions. the word polycyclic refers to more than 1ring structures that can be seen in chemistry for example. the word annular also refers to a ring-shapedstructure. so annular polycyclic lesions are ring-shapedskin lesions that usually occur on sun-exposed areas of the skin. nonindurated psoriaform is the other typeof subacute skin lesions. psoriaform means that it looks like psoriasis. nonindurated means that it is not hardas psoriasis.

subacute can be divided into annular polycyclicand nonindurated psoriaform lesions chronic skin lesions are chilblain lupus,that affects toes, fingers, nose, and ears during cold weather. these are painful, bright red nodules. nodules means a swelling of the skin thatis up to 1 cm diameter. discoid rash can also be seen. discoid refers to the disc shape of theselesions. we can divide discoid into classical type. discoid lesions can be divided into localized,which means that discoid lesions appear above

the neck,and generalized, which means that discoid lesions can appear both above and below theneck. lichen planus is an inflammatory disease thatcan affect the skin and oral mucosa. here we see a picture of whitish lichen planuson the oral mucosa. the word lichen means tree-moss as you cansee here on the picture. so this disease is looking like a tree mossbut with a whitish color. in sle patients this happen, that a discoidlesion is seen together with lichen planus. verrucous lesions or also called hypertrophiclesions are skin that hypertrophies, which means that the skin cells increase in numberand cause these hard wartlike lesions, especially

on extensor arms. mucosal lesions can affect the mucosal membranearound the teeth, the tongue, and hardpalate panniculitis or also called profundus, isan inflammation and destruction of the subcutaneous fat. tumidus lesions are pinkish urticarial non-scarringplaques usually in sun-exposed areas. plaques are elevation of the skin similarto papule, but they differ in size. so plaques are more than 1 cm in diameter,whereas papules are less than 1 cm. the chronic skin lesion are chilblain, discoid,discoid with lichen planus, hypertrophic, mucosal, panniculitis, and tumidus.

ulcers can appear on the mucosal membrane,on for example the hardpalate, buccal region, on the tongue, and on the nasal septum. inflammation can affect the heart causingpericarditis. here we see a normal normal heart on the upperpicture, and a reddish heart on the lower picture. inflammation is causing redness, pain, heat,swelling and loss of function. the heart wall rub against each other causinga typical pericardial rub sound that one can hear with a stethoscope. here we see a man having a painful pericarditispericardial effusion can also happen, which

means that fluid accumulates around the heartcausing a typical waterbottle-shaped heart on x-ray. as i mentioned, pericardial rub sounds canbe heard with a stethoscope. inflammation can also affect the lungs. so similar to the heart, there will be inflammation,pain, pleural friction rub sounds, and pleural effusionhere we can see the pleural effusion that have accumulated between the 2 layers of thelungs. this is how pleural friction rub sounds like. imagine walking on snow when you hear thissound.

we need to collect urine to find kidney problems. more than 500 mg of protein in the urine duringa 24 hour period can be seen in sle patients. this is called proteinuria, meaning proteinin the urine, which is not normal. we can also find red blood cell casts in theurine by analyzing the urine in a microscope. these casts are formed by red blood cellsthat stick together. blood in the urine is not normal. it suggest that something is wrong with thekidney. synovitis is inflammation of the synovialmembrane of the joints. polyarthritis can be seen in sle.

poly stands for that more than 1 joint isaffected. arthritis is inflammation of joint. so more than 1 joint will be inflamed causingpain. the nervous system can also be affected bysle. seizures can happen, which are hyperexcitationof neurons in the brain, sometimes leading to muscle contractions. psychosis and acute confusional state, alsocalled delirium can happen. psychosis and delirium patients usually sufferfrom hallucinations. neuropathies can be seen in sle.

neuropathy means neurons that are diseased. the neurons can be in the cranial part, peripheralpart, in the spinal cord which is then called myelitis, or single nerves can be damagedwhich is then called mononeuropathy, mono standing for single. or multiple single nerves in different areasof the body can be damaged, which is then called multiple mononeuropathy. what can we see in the blood? with a microscope we can distinguish differentblood cells. here is a picture showing the blood cells.

the blood cells originate from one cell calledmultipotential hematopoetic stem cell. this cell can produce myeloid cells, and lymphoidcells. the myeloid cells can produce erythrocytes,also called red blood cells. but in sle hemolytic anemia can be seen, whichmeans that the erythrocytes can damaged and therefore anemia will happen, which meansthat not enough oxygen is transported to the tissues. the myeloid cells can also produce megakaryocytes,that can further produce thrombocytes, also called platelets. but in sle the number of thrombocytes canbe reduced, and we call this thrombocytopenia.

penia stands for less of something, inthis case we have a penia of thrombocytes, so thrombocytopenia. the symptom of thrombocytopenia is usuallypetechiae which are small purplish spots on the skin. leukopenia can happen in sle which is a reducednumber of leukocytes, which are white blood cells, with neutrophils being the most commonwhite blood cell. lymphopenia can also be seen, which are reducednumber of lymphocytes. so the clinical criteria were alopecia, skinlesions, ulcers, diseases of the heart, lungs, kidneys, joints, nervous system and the blood.

the immunologic criteria are related to autoantibodies,meaning that the antibodies of the immune system attacks itself, instead of only attackingbacterias etc. here we have a cell, with its nucleus, containingchromosomes that contain dna. in sle, the antibodies attack your own nuclearproteins, for example your own dna, or rna binding proteins called smith proteins. so in sle we check for antinuclear antibodylevels, abbreviated as ana. we also check anti-smith and anti-double strandeddna. another immunologic criteria is direct coombstest. here we mix the patients blood together witha coombs reagent, and if red blood cells agglutinate,

meaning they stick together, then we havea positive test result. the complement system helps or complementsthe antibodies to fight infections. in sle we can see a low number of these complementproteins. the complement proteins are numbered c1 toc9, and it is the c3 and c4 complement proteins that are low in sle. ch50 stands for the total complement activity,which is also low in sle. an increased number of antiphospholipid antibodiescan be measured in sle. these antibodies bind to proteins like beta2 glycoprotein 1 on the phospholipid cell membrane.

the function of the beta 2 glycoprotein 1is to prevent phospholipid membrane to activate the thrombosis cascade. we know that thrombosis can cause death. so therefore it is very important to checkthe antiphospolipid antibody level. it is especially important in pregnant women,because these antibodies can cause spontaneous abortion and late fetal death. except antiphospholipid antibodies, sle flarescan also cause fetal death. sle fluctuate between flares and remissions. a flare is a very active disease with manysymptoms, whereas a remission is an inactive

state with few symptoms. during pregnancy, the mother should be monitoredfor any sle flares since these can lead to fetal death. so if a woman wants a child, then pregnancyshould be timed for when sle is in remission for at least 6 months. furthermore, anti-ro antibodies should bemeasured, because if anti-ro is detected, then doctors should warn mothers that thereare risks of the fetus getting a neonatal lupus or even a severe congenital heart blockwhich means the death of the fetus. so it is very important to monitor the fetalheart in this case, with for example an echocardiograph

and a 24-hour holter monitor. lets turn now to the biopsy criteria. here we need a biopsy of the kidney, whichwill show that there is inflammation, called nephritis. but it is not enough with a biopsy, we needan immunologic criteria as well, for example antinuclear antibodies, or anti-double-strandeddna. now lets see how we can treat sle patients. the first thing that we have to do is to removeany type of medication that can cause sle-like symptoms.

these are for example hydralazine, procainamide,and isoniazid. non-steroidal anti-inflammatory drugs arevery useful in sle patients, especially in controling arthralgias, which means painfuljoints. here we can use naproxen, ibuprofen, and diclofenac. antimalarial medications also help jointsproblems, but also skin problems, and they reduces the sle flares. the typical sle medication is hydroxychloroquine,but there are alternative like chloroquine and quinacrine. hydroxychloroquine can in rare cases causeretinal problems, skeletal muscle problems

and cardiac problems. so it is important that the eyes are examinedyearly. corticosteroids are usually the first linetreatment in acute severe sle. we typically begin by giving intravenous methylprednisolonefor 3 days and then we maintain the therapy with prednisone. disease-modifying antirheumatic drugs arealso very important. we can use azathioprine, methotrexate, mycophenolatemofetil, cyclophosphamide together with mesna, and in very severe cases intravenous immunoglobulin. it is well known that corticosteroid use fora long time can cause osteoporosis, which

means bone weakening. therefore it is important to consider givingcalcium, vitamin d, and bisphosphonate. so to conclude, we can say that emma has sle,which is a systemic autoimmune disease, that affects her whole body systemically. the brain, skin, heart, lungs, kidneys, joints,the immune system, and the vascular system. the typical butterfly-shaped erythema canbe seen in sle patients. thank you very much for listening!

what is panniculitis

systemic lupus erythematosus, abbreviatedas sle. this is a systemic disease, which means thatit can affect the whole body systemically. the brain, skin, heart, lungs, kidneys, joints,the immune system, the vascular system, and the list goes on. lupus means wolf. erythematosus means reddening of the skin. why did i show a red butterfly? because a very typical sign of sle is a butterflyshaped reddening of the skin. the way i remember this disease, is to imaginea wolf that attacks a woman, and why a woman?

because 9 out 10 patients are women. so the wolf bites the face of the woman causinga butterfly shaped erythema on her face. then the wolf continues to bite all her organsone by one, because this disease is a systemic disease, which means that it can affect allthe organs systemically. of course this disease has nothing to do witha wolf. but sle is an autoimmune disease, which meansthat this woman called emma have an immune system that attacks her own body, insteadof only attacking bacterias, viruses and parasites. so emma have an immune system that acts asa wolf inside her.

i will show you how we can find out if emmareally has sle by diagnosing her. and then we will look at what type of medicationswe can give her. i want you to remember at least one thingfrom this presentation. that is systemic lupus international collaboratingclinics, abbreviated as slicc. slicc is a criterion that can help in thediagnosis of sle. slicc contains clinical criteria, immunologiccriteria and biopsy criteria. we need more than 4 criteria with at least1 clinical and 1 immunologic. or we need 1 biopsy criteria and 1 immunologiccriteria.

so what does these 3 words mean? clinical, immunologic and biopsy? the synonym for clinic, is hospital. so clinical criteria stand for the symptoms,signs and lab values of a patient in the hospital. immunology deals with the immune system thatprotects you from bacterias, viruses, and immunologic criteria are usually lab teststhat detect any problem with the immune system. biopsy means that a doctor cuts out a pieceof an organ. for example, a small piece of kidney can becut out, and then the doctor puts this piece of kidney in a microscope and looks for diseases.

clinical criteria can be divided into alopecia,which means hairloss. skin problemsulcers heart diseaseslung diseases kidney problemsjoint pain problems with the nervous systemand blood diseases. skin problems can be grouped under the namecutaneous lupus erythematosus. we can divide these skin diseases into acutesubacute and chronic, based on the timing of the diseases. acute diseases are usually those that happensuddenly with a short duration.

chronic diseases are ongoing for a long time. whereas subacute means those diseases thatare not yet chronic but has passed the acute phase. a way to remember these timing are to memorize2 numbers. 1 and 3. why? because the duration of acute diseases areusually less than 1 month, subacute are 1 to 3 months, and chronic are more than 3 monthsin duration. so which are the acute type of skin problems?

butterfly erythema, which is a reddening ofthe face in a butterfly shape. it usually affects the cheeks or also calledmalar region, and therefore it is sometimes called malar erythema. it does not affect the nasolabial region. there can also be bullous lesions which areblisters that can be a mix of small grouped vesicles to large tense bullae. bullae are elevating the skin and are filledwith fluid. toxic epidermal necrolysis-like sle, is adetachment of the epidermis, the upperlayer of the skin, resulting in exfoliation, meaningthat the upperlayer just falls off.

this is very dangerous, because the skin isthe organ that protects against infections. so if you loose a large part of your skin,then sepsis can happen, which means that bacterias easily invade your vascular system, sincethere is no skin to protect you. this can lead to something called septic shock,which can lead to death. maculopapular rash is another acute sign. macules are flat spots up to 1 cm, and papulesare bumps up to 1 cm. maculopapular is a combination between maculesand papules. photosensitivity can also be seen which meansthat the skin is much more sensitive to sunlight than normally.

this can cause cause solar urticaria, whichis a vascular reaction of the skin that cause pathches. patches are flat lesions like macules, butthey are bigger than 1 cm. so one difference between macules and patchesis the size. macules are less than 1 cm, whereas patchesare more than 1 cm. so the acute cutaneous lupus erythematosuscan be divided into 5 lesions: butterfly shaped erythema, bullous lesions, toxic epidermalnecrolysis, maculopapular rashes, and photosensitive solar urticarias. subacute cutaneous lupus erythematosus canbe divided into 2 types.

one is annular polycyclic lesions. the word polycyclic refers to more than 1ring structures that can be seen in chemistry for example. the word annular also refers to a ring-shapedstructure. so annular polycyclic lesions are ring-shapedskin lesions that usually occur on sun-exposed areas of the skin. nonindurated psoriaform is the other typeof subacute skin lesions. psoriaform means that it looks like psoriasis. nonindurated means that it is not hardas psoriasis.

subacute can be divided into annular polycyclicand nonindurated psoriaform lesions chronic skin lesions are chilblain lupus,that affects toes, fingers, nose, and ears during cold weather. these are painful, bright red nodules. nodules means a swelling of the skin thatis up to 1 cm diameter. discoid rash can also be seen. discoid refers to the disc shape of theselesions. we can divide discoid into classical type. discoid lesions can be divided into localized,which means that discoid lesions appear above

the neck,and generalized, which means that discoid lesions can appear both above and below theneck. lichen planus is an inflammatory disease thatcan affect the skin and oral mucosa. here we see a picture of whitish lichen planuson the oral mucosa. the word lichen means tree-moss as you cansee here on the picture. so this disease is looking like a tree mossbut with a whitish color. in sle patients this happen, that a discoidlesion is seen together with lichen planus. verrucous lesions or also called hypertrophiclesions are skin that hypertrophies, which means that the skin cells increase in numberand cause these hard wartlike lesions, especially

on extensor arms. mucosal lesions can affect the mucosal membranearound the teeth, the tongue, and hardpalate panniculitis or also called profundus, isan inflammation and destruction of the subcutaneous fat. tumidus lesions are pinkish urticarial non-scarringplaques usually in sun-exposed areas. plaques are elevation of the skin similarto papule, but they differ in size. so plaques are more than 1 cm in diameter,whereas papules are less than 1 cm. the chronic skin lesion are chilblain, discoid,discoid with lichen planus, hypertrophic, mucosal, panniculitis, and tumidus.

ulcers can appear on the mucosal membrane,on for example the hardpalate, buccal region, on the tongue, and on the nasal septum. inflammation can affect the heart causingpericarditis. here we see a normal normal heart on the upperpicture, and a reddish heart on the lower picture. inflammation is causing redness, pain, heat,swelling and loss of function. the heart wall rub against each other causinga typical pericardial rub sound that one can hear with a stethoscope. here we see a man having a painful pericarditispericardial effusion can also happen, which

means that fluid accumulates around the heartcausing a typical waterbottle-shaped heart on x-ray. as i mentioned, pericardial rub sounds canbe heard with a stethoscope. inflammation can also affect the lungs. so similar to the heart, there will be inflammation,pain, pleural friction rub sounds, and pleural effusionhere we can see the pleural effusion that have accumulated between the 2 layers of thelungs. this is how pleural friction rub sounds like. imagine walking on snow when you hear thissound.

we need to collect urine to find kidney problems. more than 500 mg of protein in the urine duringa 24 hour period can be seen in sle patients. this is called proteinuria, meaning proteinin the urine, which is not normal. we can also find red blood cell casts in theurine by analyzing the urine in a microscope. these casts are formed by red blood cellsthat stick together. blood in the urine is not normal. it suggest that something is wrong with thekidney. synovitis is inflammation of the synovialmembrane of the joints. polyarthritis can be seen in sle.

poly stands for that more than 1 joint isaffected. arthritis is inflammation of joint. so more than 1 joint will be inflamed causingpain. the nervous system can also be affected bysle. seizures can happen, which are hyperexcitationof neurons in the brain, sometimes leading to muscle contractions. psychosis and acute confusional state, alsocalled delirium can happen. psychosis and delirium patients usually sufferfrom hallucinations. neuropathies can be seen in sle.

neuropathy means neurons that are diseased. the neurons can be in the cranial part, peripheralpart, in the spinal cord which is then called myelitis, or single nerves can be damagedwhich is then called mononeuropathy, mono standing for single. or multiple single nerves in different areasof the body can be damaged, which is then called multiple mononeuropathy. what can we see in the blood? with a microscope we can distinguish differentblood cells. here is a picture showing the blood cells.

the blood cells originate from one cell calledmultipotential hematopoetic stem cell. this cell can produce myeloid cells, and lymphoidcells. the myeloid cells can produce erythrocytes,also called red blood cells. but in sle hemolytic anemia can be seen, whichmeans that the erythrocytes can damaged and therefore anemia will happen, which meansthat not enough oxygen is transported to the tissues. the myeloid cells can also produce megakaryocytes,that can further produce thrombocytes, also called platelets. but in sle the number of thrombocytes canbe reduced, and we call this thrombocytopenia.

penia stands for less of something, inthis case we have a penia of thrombocytes, so thrombocytopenia. the symptom of thrombocytopenia is usuallypetechiae which are small purplish spots on the skin. leukopenia can happen in sle which is a reducednumber of leukocytes, which are white blood cells, with neutrophils being the most commonwhite blood cell. lymphopenia can also be seen, which are reducednumber of lymphocytes. so the clinical criteria were alopecia, skinlesions, ulcers, diseases of the heart, lungs, kidneys, joints, nervous system and the blood.

the immunologic criteria are related to autoantibodies,meaning that the antibodies of the immune system attacks itself, instead of only attackingbacterias etc. here we have a cell, with its nucleus, containingchromosomes that contain dna. in sle, the antibodies attack your own nuclearproteins, for example your own dna, or rna binding proteins called smith proteins. so in sle we check for antinuclear antibodylevels, abbreviated as ana. we also check anti-smith and anti-double strandeddna. another immunologic criteria is direct coombstest. here we mix the patients blood together witha coombs reagent, and if red blood cells agglutinate,

meaning they stick together, then we havea positive test result. the complement system helps or complementsthe antibodies to fight infections. in sle we can see a low number of these complementproteins. the complement proteins are numbered c1 toc9, and it is the c3 and c4 complement proteins that are low in sle. ch50 stands for the total complement activity,which is also low in sle. an increased number of antiphospholipid antibodiescan be measured in sle. these antibodies bind to proteins like beta2 glycoprotein 1 on the phospholipid cell membrane.

the function of the beta 2 glycoprotein 1is to prevent phospholipid membrane to activate the thrombosis cascade. we know that thrombosis can cause death. so therefore it is very important to checkthe antiphospolipid antibody level. it is especially important in pregnant women,because these antibodies can cause spontaneous abortion and late fetal death. except antiphospholipid antibodies, sle flarescan also cause fetal death. sle fluctuate between flares and remissions. a flare is a very active disease with manysymptoms, whereas a remission is an inactive

state with few symptoms. during pregnancy, the mother should be monitoredfor any sle flares since these can lead to fetal death. so if a woman wants a child, then pregnancyshould be timed for when sle is in remission for at least 6 months. furthermore, anti-ro antibodies should bemeasured, because if anti-ro is detected, then doctors should warn mothers that thereare risks of the fetus getting a neonatal lupus or even a severe congenital heart blockwhich means the death of the fetus. so it is very important to monitor the fetalheart in this case, with for example an echocardiograph

and a 24-hour holter monitor. lets turn now to the biopsy criteria. here we need a biopsy of the kidney, whichwill show that there is inflammation, called nephritis. but it is not enough with a biopsy, we needan immunologic criteria as well, for example antinuclear antibodies, or anti-double-strandeddna. now lets see how we can treat sle patients. the first thing that we have to do is to removeany type of medication that can cause sle-like symptoms.

these are for example hydralazine, procainamide,and isoniazid. non-steroidal anti-inflammatory drugs arevery useful in sle patients, especially in controling arthralgias, which means painfuljoints. here we can use naproxen, ibuprofen, and diclofenac. antimalarial medications also help jointsproblems, but also skin problems, and they reduces the sle flares. the typical sle medication is hydroxychloroquine,but there are alternative like chloroquine and quinacrine. hydroxychloroquine can in rare cases causeretinal problems, skeletal muscle problems

and cardiac problems. so it is important that the eyes are examinedyearly. corticosteroids are usually the first linetreatment in acute severe sle. we typically begin by giving intravenous methylprednisolonefor 3 days and then we maintain the therapy with prednisone. disease-modifying antirheumatic drugs arealso very important. we can use azathioprine, methotrexate, mycophenolatemofetil, cyclophosphamide together with mesna, and in very severe cases intravenous immunoglobulin. it is well known that corticosteroid use fora long time can cause osteoporosis, which

means bone weakening. therefore it is important to consider givingcalcium, vitamin d, and bisphosphonate. so to conclude, we can say that emma has sle,which is a systemic autoimmune disease, that affects her whole body systemically. the brain, skin, heart, lungs, kidneys, joints,the immune system, and the vascular system. the typical butterfly-shaped erythema canbe seen in sle patients. thank you very much for listening!

lupus profundus panniculitis

bluecross blueshield is a proud sponsor of second opinion. live fearless. hello, i’m dr. jennifer anolik. i’m here to tell you 5 symptoms of lupus. the first symptom is painful and swollen joints. over 90% of people with lupus have joint painas a prominent and often disabling symptom. lupus is usually associated with redness andswelling often in the small joints of the hands. next is extreme fatigue. sometimes fatigue can be a sign of anemiaor low red blood cells.

because lupus is a systemic autoimmune diseaseit can cause an immune reaction against one’s own blood cells resulting in anemia or otherlow red blood cells. third, is skin rashes. characteristically, they are brought on bythe sun, they are raised and inflamed, and persist for days. the classic lupus rash, known as the butterflyrash, appears on the face and spares the ‘smile lines’. but other rashes can also occur including,red patches on the body and even blistering rashes.

there are also discoid lupus rashes whichare scaly and scarring. other skin problems include ulcers in themouth and hair loss. another is chest pain, especially with deepbreathing. this can be a sign of inflammation aroundthe lining of the lung and heart. if either is present, your physician shouldidentify it when listening to your heart and lungs that would prompt additional testingsuch as a chest x-ray or cardiac ultrasound. and a final thing to look for is raynaud’s. this is where the fingers turn blue and painfulin the cold. people can also have raynaud's without havinglupus or any serious health complications.

lupus can be tricky to diagnose because someof the symptoms can mimic other disorders and there is not a single confirmatory labtest. a critical next step is to talk to your doctorand if further evaluation and lab tests point toward lupus, seek a rheumatologist. the second worst problem besides missing thediagnosis is misdiagnosing someone with lupus who has another disorder entirely. and that’s your second opinion five.

lupus profundus symptoms

bluecross blueshield is a proud sponsor of second opinion. live fearless. hello, i’m dr. jennifer anolik. i’m here to tell you 5 symptoms of lupus. the first symptom is painful and swollen joints. over 90% of people with lupus have joint painas a prominent and often disabling symptom. lupus is usually associated with redness andswelling often in the small joints of the hands. next is extreme fatigue. sometimes fatigue can be a sign of anemiaor low red blood cells.

because lupus is a systemic autoimmune diseaseit can cause an immune reaction against one’s own blood cells resulting in anemia or otherlow red blood cells. third, is skin rashes. characteristically, they are brought on bythe sun, they are raised and inflamed, and persist for days. the classic lupus rash, known as the butterflyrash, appears on the face and spares the ‘smile lines’. but other rashes can also occur including,red patches on the body and even blistering rashes.

there are also discoid lupus rashes whichare scaly and scarring. other skin problems include ulcers in themouth and hair loss. another is chest pain, especially with deepbreathing. this can be a sign of inflammation aroundthe lining of the lung and heart. if either is present, your physician shouldidentify it when listening to your heart and lungs that would prompt additional testingsuch as a chest x-ray or cardiac ultrasound. and a final thing to look for is raynaud’s. this is where the fingers turn blue and painfulin the cold. people can also have raynaud's without havinglupus or any serious health complications.

lupus can be tricky to diagnose because someof the symptoms can mimic other disorders and there is not a single confirmatory labtest. a critical next step is to talk to your doctorand if further evaluation and lab tests point toward lupus, seek a rheumatologist. the second worst problem besides missing thediagnosis is misdiagnosing someone with lupus who has another disorder entirely. and that’s your second opinion five.

lupus panniculitis symptoms

bluecross blueshield is a proud sponsor of second opinion. live fearless. hello, i’m dr. jennifer anolik. i’m here to tell you 5 symptoms of lupus. the first symptom is painful and swollen joints. over 90% of people with lupus have joint painas a prominent and often disabling symptom. lupus is usually associated with redness andswelling often in the small joints of the hands. next is extreme fatigue. sometimes fatigue can be a sign of anemiaor low red blood cells.

because lupus is a systemic autoimmune diseaseit can cause an immune reaction against one’s own blood cells resulting in anemia or otherlow red blood cells. third, is skin rashes. characteristically, they are brought on bythe sun, they are raised and inflamed, and persist for days. the classic lupus rash, known as the butterflyrash, appears on the face and spares the ‘smile lines’. but other rashes can also occur including,red patches on the body and even blistering rashes.

there are also discoid lupus rashes whichare scaly and scarring. other skin problems include ulcers in themouth and hair loss. another is chest pain, especially with deepbreathing. this can be a sign of inflammation aroundthe lining of the lung and heart. if either is present, your physician shouldidentify it when listening to your heart and lungs that would prompt additional testingsuch as a chest x-ray or cardiac ultrasound. and a final thing to look for is raynaud’s. this is where the fingers turn blue and painfulin the cold. people can also have raynaud's without havinglupus or any serious health complications.

lupus can be tricky to diagnose because someof the symptoms can mimic other disorders and there is not a single confirmatory labtest. a critical next step is to talk to your doctorand if further evaluation and lab tests point toward lupus, seek a rheumatologist. the second worst problem besides missing thediagnosis is misdiagnosing someone with lupus who has another disorder entirely. and that’s your second opinion five.

lupus panniculitis treatment

bluecross blueshield is a proud sponsor of second opinion. live fearless. hello, i’m dr. jennifer anolik. i’m here to tell you 5 symptoms of lupus. the first symptom is painful and swollen joints. over 90% of people with lupus have joint painas a prominent and often disabling symptom. lupus is usually associated with redness andswelling often in the small joints of the hands. next is extreme fatigue. sometimes fatigue can be a sign of anemiaor low red blood cells.

because lupus is a systemic autoimmune diseaseit can cause an immune reaction against one’s own blood cells resulting in anemia or otherlow red blood cells. third, is skin rashes. characteristically, they are brought on bythe sun, they are raised and inflamed, and persist for days. the classic lupus rash, known as the butterflyrash, appears on the face and spares the ‘smile lines’. but other rashes can also occur including,red patches on the body and even blistering rashes.

there are also discoid lupus rashes whichare scaly and scarring. other skin problems include ulcers in themouth and hair loss. another is chest pain, especially with deepbreathing. this can be a sign of inflammation aroundthe lining of the lung and heart. if either is present, your physician shouldidentify it when listening to your heart and lungs that would prompt additional testingsuch as a chest x-ray or cardiac ultrasound. and a final thing to look for is raynaud’s. this is where the fingers turn blue and painfulin the cold. people can also have raynaud's without havinglupus or any serious health complications.

lupus can be tricky to diagnose because someof the symptoms can mimic other disorders and there is not a single confirmatory labtest. a critical next step is to talk to your doctorand if further evaluation and lab tests point toward lupus, seek a rheumatologist. the second worst problem besides missing thediagnosis is misdiagnosing someone with lupus who has another disorder entirely. and that’s your second opinion five.

erythema nodosum and lupus

with vasculitis, you have “inflammation”,of the “blood vessels”, and even though this can happen in arteries or veins, we’regoing to focus on vasculitis in arteries because it’s way more common. vasculitides are categorizedby the size of the blood vessels they affect, so we have small-vessel, medium-vessel, andlarge-vessel vasculitis. typically vasculitis is due to an autoimmune disease, where theimmune system confuses a part of normal body as a foreign invader, and there are a coupleof ways this might happen. sometimes the body confuses the innermostlayer of the blood vessel, which is the endothelial layer, with a foreign pathogen and directlyattacks it. to be a little more specific, the white blood cells of the immune systemmix up the normal antigens on the endothelial

cells with the antigens of foreign invaderslike bacteria simply because they look similar - this is called molecular mimicry. this autoimmuneconfusion is thought to be the cause several types of medium-vessel and large-vessel vasculitides. other times the immune system attacks healthycells that are near the vascular endothelium, and the endothelial cells are only gettingindirectly damaged. this is the situation in many small-vessel vasculitides, where theimmune system attacks white blood cell enzymes or other non-endothelial cell targets. once the endothelium is damaged either directlyor indirectly, almost all vasculitis diseases progress in a similar way. the damaged endotheliumexposes the underlying collagen and tissue

factor, and these exposed materials increasethe chance of blood coagulation. the blood vessel walls themselves get weaker as theyare damaged, making aneurysms more likely. and finally as the vessel wall heals, it becomesharder and stiffer because fibrin is deposited into the blood vessel walls as part of thehealing process. and actually, that’s vasculitis in a nutshell.the different types of vasculitis for the most part only vary depending on how theyare triggered and where in the body they cause problems. people with vasculitis have generalized symptomscaused by the inflammatory response of the immune system. symptoms like fever, weightloss, fatigue, etc. more specific symptoms

occur usually based off where in body thevasculitis is occurring, and which organ is supplied by that blood vessel. reduced bloodflow caused by vasculitis can cause organ ischemia which can happen in two ways. first,blood cells clump onto the exposed tissue factor and collagen on the inside of bloodvessels forming blood clots that and can restrict blood flow. the second way is caused by thehealing process of the blood vessel. as fibrin is deposited in the vessel wall, the wallsbecome thicker and bulge into the vessel, reducing the diameter of the vessel lumen. alright, now that we have the general ideaof vasculitis covered, let’s take a look at some specific conditions, starting withthe large-vessel vasculitides.

giant cell arteritis is a vasculitis thataffects branches of the carotid arteries. vasculitis in the temporal branch of the carotidartery is the most common location and causes headaches. vasculitis in the ophthalmic arterycan cause visual disturbances, and vasculitis in any of the arteries that supply the jawmuscles can cause pain when someone chews food - called claudication. giant cell arteritisaffects older individuals (typically more than 50 years old) and women more than men,so a grandmother would be in a high-risk group. classically, this type of vasculitis causeslots of inflammation and it results in a really high erythrocyte sedimentation rate (or esrfor short) - sometimes over 100! in giant cell arteritis, a biopsy of the affected arterywill show giant cells embedded in the internal

elastic lamina, which is a thin layer of elastictissue that separates the tunica intima and the tunica media. to be clear, these giantcells are actually not individual cells at all, but rather granulomas - a group of monocytesthat are packed tightly together, and look like one giant cell. now giant cell arteritisis segmental, which means that if you look at the entirety of an affected artery, you’llsee only sections of the artery are actually affected. this means that when biopsies aredone, you have to take a long section of the artery and examine it under a microscope.it also means that, if you don’t see any affected tissue, you can’t for sure ruleout the disease because it’s possible you took an unaffected section of the blood vessel.you can treat people with giant cell artertitis

by giving them corticosteroids, which weakensthe immune response. people whose ophthalmic artery is affected and don’t receive treatmentare at a high risk of blindness, again because poor blood flow to the eyes causes ischemiaand irreversible blindness. alright, so another large-cell vasculitisis called takayasu arteritis, and it’s very similar to giant cell arteritis except fortwo key differences. one is that it usually affects asian women that are under 40 yearsold where giant cell arteritis usually affects people over the age of 60. and two, it affectsthe arteries that branch off from the aortic arch, particularly around the branch points.if the inflammation occurs around aortic branches that serve the upper extremities, it causesa weak or nonexistent pulse. if the inflammation

occurs around the aortic branch that servesthe head, then it causes visual and neurological symptoms. histopathologically it’s quitesimilar to giant cell arteritis because in takayasu arteritis you still see giant cellsand granulomatous inflammation in the internal elastic lamina of the blood vessel. in addition,the erythrocyte sedimentation rate will be elevated, and takayasu arteritis is treatedwith corticosteroids. let’s move onto medium-vessel vasculitisdiseases. these vasculitis diseases typically affect a wide range of muscular arteries thatsupply organs, which gives the conditions a wide range of possible symptoms. the mostcommon type of all vasculitides is kawasaki disease, and we’ve got a separate videoon kawasaki disease, but for now it’s important

to note that it affects the coronary arteries,the muscular arteries serving the heart. next there’s polyarteritis nodosa, whichis thought to occur when the immune cells directly attack the endothelium, confusingit with hepatitis b virus. now, polyarteritis nodosa causes transmural inflammation, whichmeans the entire wall, the tunica intima, media, and adventitia are all affected. thisinflammation causes the vascular wall to die through all three layers of the artery andfibrosis occurs as the vascular wall heals, this process is called fibrinoid necrosis.the fibrosed vessel wall is left weak and prone to aneurysms, so some areas start tobulge out through the weakened walls. so if you step back and look at the artery you seethese fibrotic aneurysms which are hard bulges

down the length of the artery, and they looklike a “string of beads” on angiogram. this pattern is quite unique among the variousvasculitides. organ ischemia in the distribution of affected arteries is the main complication.if the renal arteries are affected, then a person will have hypertension (remember kidneysregulate blood volume). if the mesenteric artery is affected, a person can have mesentericischemia and severe abdominal pain and gastrointestinal bleeding. if the arteries affecting the brainare affected it can cause neurological symptoms, and if arteries supply the skin are affectedthen it can lead to skin lesions. treatment is aimed at reducing the vessel inflammationand generally includes corticosteroids. another medium-vessel vasculitis is buerger’sdisease, named for a nyc pathologist not a

hamburger. it’s other name is thromboangiitisobliterans, which literally translates to clot vessel inflammation blockage, and asthe name suggests this vasculitis is notoriously for causing blood clots in tiny arteries inthe fingers and toes, which leads to ulcers and eventually dead tissue in these digitsand eventual autoamputation. not fun. buerger’s disease typically affects men between theages of 20-40 years and the biggest risk factor for this vasculitis is the use of tobaccoproducts. in fact, the thought is that tobacco might be the trigger for the autoimmune responseagainst blood vessel. stopping the use of tobacco actually slows down (but doesn’tnecessarily stop) the disease and need for amputations in most patients.

alright onto small-vessel vasculitis. small-vesselvasculitis affects small vessels like arterioles, capillaries, and venules. in the diseases,b-cells mistakenly target their antibodies to granules made by a person’s own neutrophils.in a sense, one immune cell attacking another. the antibodies are called “anti-neutrophiliccytoplasmic antibodies” or ancas for short and they are mainly of the igg type. the disease granulomatosis with polyangiitis(gpa) which used to be called wegener’s granulomatosis, is one of these small vesselvasculitides. the b-cells release an autoantibody called cytoplasmic antineutrophil cytoplasmicantibody or c-anca. yep, the name is hilariously redundant - with cytoplasmic included twiceto drive home the point. c-anca targets and

bind to a specific neutrophil granule calledproteinase 3 which is embedded in the membrane of some neutrophils. once c-anca binds tothe neutrophil, it causes the neutrophil to release oxygen free radicals, which enterthe nearby endothelial cells damaging them indirectly and causing vasculitis. on a biopsy,you can see evidence of inflammation and granulomas in the blood vessel wall. gpa affects thenasopharynx, lungs, and kidneys and usually occurs in middle-aged males. people with thedisease can have chronic pain caused by sinusitis or bloody mucus from ulcers within the nose.over time, the nose itself may even cave in or curl, a condition called a saddle nosedeformity. blood vessel inflammation in the lungs and air passages can also make breathingmore difficult causing air passages to constrict,

and ulcers can form causing bloody coughing.in the kidneys, the inflammation restricts blood flow to the glomeruli, causing themto die and leading to decreased urine production and an increase in blood pressure since thekidneys are no longer as efficient at regulating blood volume. gpa is typically treated withcorticosteroids and cyclophosphamide, but relapses in the disease are common, and thatmakes sense. the presence of c-anca is the main cause of the disease, and if it keepsattacking the granules from within neutrophils, there is a good chance the disease will return. another small-vessel vasculitis that is verysimilar to granulomatosis with polyangiitis is microscopic polyangiitis. it’s so similarin fact, that you need to rely on some clues

to help distinguish them. microscopic polyangiitisdoes not affect the blood vessels of the nose/sinuses, only the kidneys and lungs. you also won’tsee the granulomas in the blood vessel walls like you would in granulomatosis with polyangiitis.the third difference is you won’t find c-anca antibodies. instead you’ll find p-anca antibodies(the p stand for perinuclear), which is just a different type of anti-neutrophilic cytoplasmicantibody reacting with the neutrophil granule myeloperoxidase instead of proteinase 3. youtreat microscopic polyangiitis the same way you treat granulomatosis with polyangiitis,corticosteroids and cyclophosphamide, and it’s also common for it to relapse. churg-strauss syndrome is very similar toboth granulomatosis with polyangiitis and

microscopic polyangiitis. it too is causedby p-anca antibodies and it causes similar symptoms such as sinusitis, lung damage, andkidney damage, but it also causes gastrointestinal, skin, nerve, and heart damage like some medium-vesselvasculitis diseases. a lot of the time churg-strauss syndrome ismistaken as allergies and asthma because they all have similar symptoms. that, and likeallergies and asthma, churg-strauss causes a lot of eosinophils to float around in theblood. actually people who have asthma and peripheral eosinophilia are more likely todevelop churg-strauss syndrome because they both have elevated eosinophils. also justlike granulomatosis with polyangiiti, granulomas can form.

next up, henoch-schonlein purpura. now unlikethe other small vessel vasculitis diseases we’ve talked about henoch-schonlein purpura(abbreviated at hsp) doesn’t involve anca antibodies. instead, we find elevated levelsof the iga antibodies floating around in the blood. now iga is an awesome antibody thatis found in our mucosal cells, which are cells that are in some way exposed to the outsideworld, for example cells in our lungs and our gastrointestinal tract. in hsp, the person starts making iga thatis directly targeted at their own endothelial cells because of molecular mimicry. this goesagainst the general trend of small-vessel vasculitides being the result of indirectdamage. symptoms depend on where the iga-mediated

attack on small blood vessels happens. sometypical places is the skin blood vessels around the buttocks and legs, which leads to significantskin discolouration that looks like blood is pooling under the skin surface - calledpurpura. one indication that the disease is henoch-schonlein is that the skin discolorationis palpable, as in you can feel it raise above the normal skin. remember the fibrosis ofthe blood vessel walls hardens and makes it palpable, just like in polyarteritis nodosa.if the iga attacks the blood vessels in the gastrointestinal tract it can cause abdominalpain, and if it attacks the blood vessels in the kidneys, it can lead to hematuria (bloodin the urine) and eventually affect the kidney’s function which is called iga nephropathy.

just like the other small-vessel vasculitisdiseases, henoch-schonlein purpurpa resolves on its own but it can reoccur. generally itis only treated with steroids if the symptoms are severe. and there you go! that’s vasculitis!

lupus nodules

earlier this month i saw a patient who wasreferred to me by his general practitioner with phlebitis. his gp had been treating himwith antibiotics and if anything, his leg was getting worse. now treating phlebitiswith antibiotics is simply wrong and i am going to tell you the truth about phlebitis.phlebitis is simply a medical term indicating that there is inflammation in the vein. mostcommonly it affects the superficial leg veins and it is associated with localised swelling-- a lump- which is red, tender and warm and sometimes the lump actually feels hot andpainful. usually phlebitis comes on out of the blue for no apparent reason but very occasionallyi see phlebitis as a complication of some cancers, intravenous arm catheters used inhospital -- drips - or sometimes as a reaction

to some very irritant intravenous injectionssuch as chemotherapy. i haven't seen a case of phlebitis due to bacteria for years andthat happened in a drug addict who was injecting into a leg vein with dirty needles. the standardusual case of superficial leg vein phlebitis seen by a gp does not need antibiotics. antibioticsmay do more harm than good. now until recently, phlebitis in superficial leg veins was thoughtto be a rather trivial condition and many doctors dismissed phlebitis as being of noreal significance. even the term phlebitis is often misunderstood and misused. many peopleincluding doctors describe any discomfort in their veins as being phlebitis. to absolutelysure that the problem is phlebitis, a duplex ultrasound scan is needed -- the ultrasoundappearance of phlebitis is characteristic

and diagnostic. the vein wall is thickenedand there is a variable amount of clot inside the vein. a scan is the only way of checkingthe vein directly and confirming that the vein is inflamed. ultrasound has also revealedthat a very important group of people with phlebitis either already have a dvt or theyare at risk of developing a deep vein thrombosis. the inflammation in the wall of the veinsaffected by phlebitis activates clotting of the blood inside these veins. this clot canextend or spread from the superficial vein into the deep vein. so this is another veryimportant reason why everyone with phlebitis should have a duplex ultrasound scan. a duplexscan is the only way to correctly identify people who already have a dvt and who needtreatment to prevent that clot leaving the

leg, travelling around the body and lodgingin the lung -- a serious condition -sometimes fatal- called a pulmonary embolism. a duplexscan will also determine whether these people with phlebitis are at risk of a dvt and whoneed preventative treatment. so the first important message is that everyone with phlebitisshould have a duplex ultrasound scan. so how should superficial leg vein phlebitisbe treated? well we can only offer the correct treatment for phlebitis if we know the resultsof the duplex scan. the scan may show that the phlebitis is only in a small area andthat only a limited number of superficial veins are affected. if there is very littleassociated clot in these superficial veins and if this clot is well away from the deepveins, then treatment with aspirin or aspirin-like

medication called non --steroidal inflammatorydrugs and compression stockings may be sufficient. a good medical sock will support the veinwhile it is recovering and the anti-inflammatory tablets or cream will ease the swelling andpain. if the phlebitis is extensive or if the clot in the superficial veins is alreadyclose to the deep veins, a course of blood thinning injections -- anticoagulant heparinmedication- is needed to reduce the significant risk of developing a dvt. of course if thescan shows that a dvt has already formed, full anticoagulant treatment for several monthsis needed. so the correct treatment of phlebitis requires a scan.so in summary, phlebitis is not an infection and antibiotics are not the correct treatment.phlebitis is not a trivial condition, it can

be serious and may cause a deep vein thrombosis.everyone with phlebitis should have a duplex ultrasound scan to confirm the correct diagnosis,to check for dvt and to guide the correct treatment.now, if you are interested in vein problems and you would like to keep up to date, pleaseclick the button above and subscribe. that way you will be among the first to see ournext video. why not leave a question in the box below.i'd love to hear from you and i will do my best to get back to you as soon as possible.thank you for watching.

lupus profundus treatment

from uh... it is still since the springhill players strangled play tonight lead the styling players loses money willweigh and this is not even lower tonight's lady astor presents the screenguilt players and one of the most charming screen adventures of the pastyear the pied piper pineapple shoot

it stars monty woolley as the twentiethcentury typewriter and roddy mcdowall as ronald monty woolley tells a story my name is power and if you wonder why did the frenchalps didn't you nineteen forty while out of the things that we you know i think that is the reason concerns noone would myself at the moment you find in the middle ofjuly meeting and waiting for the light beer i'veordered

only vaguely aware that the two youngtraveled all children out in the room you see i love it but it seems that mymind but look beneath it and it does we would receive leash elasticity we haven't mice period except for god is uh... jessica that'squite all right mister harris anybody know chic chic kathleen she

is too high fifteen five seats in the united states imagine making it exceeds fixes airheadi'd sit down texas said and uh... the california that's right catherine virginia virginian cigarettes you know and the florida

rochester that's not a state of the city may i inquire what role do they want toask you now listen you'll be doing a great favor by keepingyour irresponsible conjectures to yourself of they'll all run it i hope you're not knowing just how outit's not just in the united states is sitting on a state purchases the citycults used to cap it off

february corroboration for thatstatement beyond your bed unsupported with at the top up just how close you know that not just asa state i've never heard the question raisedfall and what would you say is that if i didn't want to the five months old have stage watchers in that case naturally i'd be compelledsays it's time for the mission used here will you try to get on that line is thatright

if that happened at the white men todayso that the cockpit caps we k k k it up cap all right holder it's yes

it is what i have seen issue it is a good restrictive like hitler isjust twelve it is better if we make the inflaming jet you click finish but of course that'syour retired army to informs lowered in the first one were to be fiveso far she was going to be like will you please inform the managementlargely whodunit welker in paris under ordinary circumstances i shouldn'tbe a distributor packing new jersey my husband goes back to geneva tonight

his post is there want competition goes down if anything happens apollo so there's noquestion now that all the problems with in heat that would go out this week inthe next pretty little couple staple reluctantlylast year if the children issue should fit them someplace wherethey'll be statements just eat of mister holland's would you take them to go back toengland to what just a few nothing

most of its beaches you will need that boy it to me cities i know about this afternoon bobby didn't need to be approved he's been very good chance and she would be no trouble at all seal i did see the abilities of salt but the market

the ones that discovered all it wasnever about was the little rock just accuses st dot is not the state as a question for the authorities todecide it was his stubborn dogmatic attitudei'm sorry annexing dot expect pollen fools flip-side of that uh... uh... celery is really too much willneed to file for hand dole i have noted pitches whatever i'm sure it difficult these two are very uh...

capable of clothing and uh... uncoatedthemselves and uh... uh... continues those in the convention religion suits do in the in the visit gotta live at theend of the susan smith to over many years them and file from robots if you feel that they could exercise ameasure of patients in sympathy with the actually that uh... them something tothat

come out of my word well rational process i sometimesregretted once on the trade the children with theleast of my troubles also i but does it really doesn't hateful ronald i know my rights as avisa that user let

when does the next day leave for parisis you do not understand the japanese have trust in allah your child is blakeymi vida times without friday no doubt about it the trains they definitely have stopped but lobbyists and discover the possiblybe the morning so obviously be tonight on the for thequote realization once again we would on our way some bags privacy running

is the killer who thank you think it would be hikes thatreview paprika selfless sittin insufferable ticket as yes cuts all over the top of various over if means you don't think it's uh... you're on and answers and you who is this child misconduct do you remember that makes it

station that's nice her mother work well it wasn't a mother said that was a room is out watkins display children got beat eachother she wanted to just take them to heart in renton dickens hoped that's a problem he's awake

what possible interest which is a bit so uh... that's it just a hotbed dot they didn't have anywhere to go a littledon't you see you have one come all there so what you want me caught by thegermans would you say well that's not the point sir how will this make it clear attentive to the students

market child uses campaigns was once said that i have nothing butcover against you personally is simply that i do not proposed to beimposed upon doesn't understand it is sad that perhaps you will talk to people in the dark about it i donot like children particulate u but what we get this august with severalof the five days yes jewelry intelligent way to deal with it

how use client interview fear the lofty he available tell isn't easy never on thank you mister howard we won't be any problem at all program accountability it don't kill we'll show you i'm not in the habit oftraining company to develop a box land as their own mind and they wereright

renouncing lane meanwhile the love of god and what wasin that the senate side of the film that they've done does after that the buses that run into so we move forward on forms and wewalked to a darned then loses he barred themself overnight was an image of theplace eurodns she dumped him listen there were therewants and

old is one wonders now sir so i proceed you have been are you with us now hecan't talk he's means keen how did you learn that terms the cat call mills vetoed well i think you'll pass it he said

brodry he was in the process his father and mother stink in the pastnovel blitzen he can speak i don't think he can deny that flowers even longer classy teens would reflect the view of the largestwill look at uh... uh... of

driving you want to ask him critiquing good boy election throughout the city any conscience the just like this season and so i wasn't looking

parking options right if it doesn't matter in the least horses on one goal of all other thoughit was l candidates all getting pizza processes not associate or industrial state not such an old for the body after allthat ice it's a nazi my memory and they aregoing to the tragedy of a roller coaster

geography use of a defiant i'm stillpretty good alike and see that's a has distributed knowledge it too policies financing only going to be a do you think running i'm not exactly and i have adefeat i promised you a mother articulatingthem and that is precisely a player we willgo

grads i come up with hired taipei starting monday will a and roddy mcdowall before we hear acts to upward from our hostess lady estate deep in the secret hidden places of manywomans huh is the belief that she could be quitefascinating tony should come to mind to it and anyway that's quite true

a woman can make himself look morefascinating and we just dont is with the fetus whichis just sent a few and frame it as you wish a man of fewpainting and then take that step perhaps the most important step of all is to find a truly flattering facepowder bob and i mean not just to coveringhabash and i'm not just in my first film off coating on the skin but if they spotted and extra glamourand beauty of its own

so many women have written music justchanging dvd s to face powder has made of training changing their opinions they say no powder does wonderful thingsfor the appearance of the skin helps to make it look style keeps movingmore into it they say it gives their skin a sickening clean fresh translucent no every one ofmy hands when i was a very good reason of why myparents are unusually flattering yesterday's partisan just mixture sifted regarding the party's name

my powder goes through the patenting anexclusive maybe estate when hurricane process the tiny particles of colin powell didbelong together with a force of hurricanes and to have perfectly normal until more longer divided in colas butnow unified in smoke no longer separate part of particles at a picnic vatican pyramid beauty foryour scheme

tried ideas to please contact and see how much smoother they've beenon the project how it helps hide loans and emissions see how deep did not need to change that i mean he has to base cabinets instantyou buchanan injuries to the appearance of your skin pam uh... acts to of the twentieth century fox but thatshould not try and plan for starring roddy mcdowall as models

and money willie as the modern piedpiper who continues our story one man courtroom a little cavalcade plotted solely onquality the going was more difficult now north german soldiers everywhere one of the children could pass has made his speaking fluent french i myself about one hundred using thesegreat cities of the money still i had no illusions as to whatwould happen given we would question

flooded the level of the gate at two of the to the developed their ownlittle ability to get crazy too crazy just attached well i'm not happy about that problem mt open so that you made a babbling a bit you know so i think whatmight be able to choose

overdoing it where of pop up this other expressionshow do i look wonderful satpathy awful and must say i have never considered bysome of the evidence s yet alone but at least we got through to a lot ofthe u dot div to be specific to the home of the root of all familyitself my son that i had spent the previoussomewhat with them that separates and i was hoping that would help us now

non-commercial use they did but i would love to all of that stuff ofabout but they are just quickly into the house hollis and last summer but um... some of them i did not have last week well they thought it was wrong but wasin the gulf this is rob hall to find that

uses sister she's up uses rules this is the area these there so icic teams will have we seem to have a new one when did he joined us running areleaving that aside all since yesterday his eulogy you'll here's live in thistrip that doesn't seem to miss

reduce the marvelous himself his doubts he can easily completely how do you know terrace well big business she doen't do you speak dept

do you unjust and dutch unionist but he told fitted with language teacher castello you see that is it something still inthe future and communication g_p_-one immediately like something to keep calmly stated about whether the calamity received theconviction land convoy truthful

candidate you andy stein that uniquely kienxinh hehit his head no ourselves involved you with your mother i was hoping to see control we have just heard from my family forseveral months aggressive good to have suffered the loss you know my son john of course

he's cooks i regret to inform him of his beard really are if you know shot down alittle bit of two months ago here but it is the coverage so plan isdead took three of them to bring him down mhm he has been ninety three we have teaching begin to tell you

newman kilometers from here and with the wind not completed from disgruntled lifting incompleted needs and so for a long timeto complete indeed except to complete

peers attitude filled cooler darkened frankly i have no idea what we've donewithout michael through fred she made arrangements for the youngfriend fishery he was going to renew joined at all and he would take us with your money reelection highfalutin as on the coverof the dog i didn't buy the drugs lumped

together at the water's edge in reviewedon because related to this issue the cold i'm sure you won't come with us to evenissue reachable like he's he patients have to attend please for eighty alphonse you must think disturbance

and english gentleman to having a courseplans with five children and just wanted to get the baikal mckeon most designing device happens to be the troops anguished love it was the mostly the probable with you major pieces if your intentions to frighten me you'rewasting your press alot alone on the beating the shit you know that i wanted to demonstratethat this was bombed details visit

didn't do it but i'm glad to navajo youknow who constantly like you u_n_ challenged jumped on behalf of the other states will not tell perhaps that you would youwould tell us how that message dot blot england assaulted you precisely nothing because there's nothing i know all ethically at my house

first of all i say a great job because he didn't get home off course not that's true how you'll come to the house would you like to talk rigid bc i read cdv hungry but unless you indicate compositionalpossibilities more pleasant than those

of you that before uh... surrealist content to save mybreasts the executed sound on this morning athow lott does that mean anything to you it it is not a good across the newsroomhas died but faced with the alternative otherthan this visit with you uh... show he was most happy to go do you have college you possibly

if you'll pass by you at least in makelittle one what did you think you would use it the note i hadn't stopped centered on the guy i suppose that babysit for their may come up with adual stab don't think so i have a married off of it should they go home for them to the waris over

however i do not believe won the wellthat is totally about the shooting or i will say anything you wish if only youlet them go about yours jewish which that one he's got it didn't occur to me that iask you people are also jewish in america except that you should

i don't believe they were to end up inthe child even adjournment image and and so that's it are you positive there we have alreadysent them from any thousands wound children don't know any conditions thati know as to color race all religion but none

weekend up here mister halat how would you like to continue at thebuilding not without the children that is what i need listen carefully i have a little girl like you my knees father of my younger brother was killedin that you and motherhood and later was not korean

so the head to dispose of her account fortunate problem of the chenthe names have alien have jewish g happens to be it's which she would be better off with mike on the blood on the unitedstates she would be safer u if you wish

my brother's name is all but or but these is an american citizen because it doeshave his own in new york state in this city in the latest the city of largest artist from new york r_u_ pas de la casaand positive what are you talking about and get a hold of alleges that the wholepolicy of apartheid anyway let me give you his address laterbut independent was the one on the road

by means of the fire out doesn'tstronger where they are now way and lives in mother to mostly yes uh... orno since taking cantana problem on sending consent i'll just enough to say good nightgoodman announced to hide the rahman there the uh... rhythm that i think i ought to give up words that's all that you rememberalittle discussion regarding that

also might all i know but uh... could it's you role use pretoria love only allow it phony war on it his novel state all it's a city the city of new york state well now is a godsend we both should make that same state uh...

generate good boy love it one of these days you make of this greatenglishman thank you your money well a m roddymcdowall for bringing us tonight the heartwarming story of the pied pipers lady astor screen guilt players thankyou indeed civil right is pleasure as well as mineto be a list of rather we're all aware the benefits of theseproblems go to support the motion picture country house and clinic and we know how important this charityis to our industry thankyou and good

night now and now before we tell you about nextweek's program here is a word from one of america'sbest known beauty i thought it is lady estate you just can't use maybe a stiff aspartan without looking younger lab more exciting now i'm not saying it's thousands ofwomen the same women all over the country you'velistened to me just as you are listening

and decided to try mascot and see forthemselves if eight years really so different fromon the part of so much more capital lab and the history they've convincedthemselves yes everyday women are discovering thatwhen he has to face powder made a new way am i talking between hurricanemethod is a good night for the new anddifferent kind of face powder not only of the texture soft and smoothabout five and the texture of karnataka not only does it clean longer innkeeperskin looking cool and fraction hot weather

but even if she needs to be put on oneninety chains that i had extra bowmanexcitement you know some a scheme so why don't you have to try and eightys defaced project there's no better judge in the wholeworld in their own eyes and unless they are very different fromthousands of others angela that like you see in your mail will convince you that may have to facepowders must flattering powder and and next week

that lady especially in guild playerswill present a delightful radio version dot skylark it will stop custom fostered alan joslyn and gender but heres they showed a less money will they consume the scene in thetwentieth century pops production holy matrimony roddy mcdowall appears to thecourtesy of twentieth-century fox and concern be seen in the metro goldwynmayer production lassie come home music on tonight's program was arrangedand conducted by wilbur acts

to help your government safety in byhave a larger size oblivious to pastry and same time you will save you somemoney to invest in war bonds and stamps this is truman rightly speaking forletting us stay saying thankyou and good calmed it is still resents the screen goesblack personnel play tonight skylark co-starring players this isn't sarah-jane sis's presentpasta and this is our jobs

tonight lady astor presents the screenguild players in an adaptation of paramount pictures delightful comedy ofthe advertising business skylark ice and some great deals and it stars ginger rogers as lydia canyon preston foster as her husband's tonycanyon account executive of a big advertising agency and alan joslin as jim blake has our story begins

tony and lydia kenyon are celebratingtheir fifty wedding anniversary most of the guest of a riot and libya is on the way up the phone isin the very end distressing she stops the moment to talk to aboutthat arsenal yes madam how did not lucky is just a feels incamels over houston when we have guessed i always rememberthat red kept cigarettes is one of

mister king is largest clients threehundred thousand a year in advertising and this is saying is that that's intake i wouldn't be too sure did you eversmoke a red cap cigarette and said our did you put abercrombiesoap and all the bathroom yes pat usually taken the lavender wrapper now what do you suppose we can do aboutvalentine's dog food we can just put it on the piano with asign reading help yourself can wait

or heaven forbid net in it on spread on a cracker when you look atrate be like chopped liver none of them comes just a thought well see what you can do another realistic and those in other words because coming on well how does it feel of the americanpublic five years

well i think i'm going to like it what alovely russia babe just take your time sir title i've got to rescue the horse meat we use the ride are you referring to mr mrs valentine video you mustn't forget that fredvalentine is my biggest advertising account i'm going to win an even biggeraccount from him tonight if we can only handle myrtle ballantyne right you know what video i think she wants isto give her a cook

on o_j_'s hand and in a bout it here she said you know i was a skinnyand you have a wonderful cook nancy burt finally she just came right out mass forwell would you go about it park area metal very neatly i thought i made it very clear to me that this isa free country the sleeves with a slight israelliberated by ram lincoln in eighteen sixty five boise news to her where you are not verybright

what you want me to do get down on myknees wrap-up michael can have it delivered to the valentine's house withan apple animal this is no time to be losing your temper don't you realize that valentine's dog food is my biggestaccount it means an extra million in advertisingwhich i make it tonight one three years ago when we want to spend on vacation onthe island we bought we had to go to palm beach becausethat's when that will ballantyne montego to whatever america wanted to do we haveto do it three my role as a jerk

but we got this house by going to palmbeach that time to read and i have a million bucks moreadvertising as we got the house all right somewhere along the line i lost you after having satanic and it's time to time let's getdownstairs so i guess and michael in total brad whether and how about times andi've always tony wonderful just wonderful and you in the stands when itbut now the jury will hear you know tell

you haven't guessed i think that thecourt your house is so much that doesn't mean too cannot on the book uh... it kapiti that the off no darling why keep a secret any longer wemight as well tell 'em out alan what if i didn't know about the on lover when she tries to be cute

we remembered how you enjoyed muddiescooking and lydia said to me darling why not ask missus valentine if she wouldlike to have maddie how do you know what to say i know what to say that i don't thinkthey say it would you like excuse me for a momenti've just bought a step outside and put the ball and chain on our show fair alone did you walk out on the anniversaryparty yes

so that i dull business timeout timeout mobsters home i'm sorry but i'm worse off than you areright and left michael ballantyne really yes you know the duchess of dark meat was on may twenty million bucks byfinding out what to do with the horse after bing crosby's through with it hehe

higher news michael occasionally myname's blake jim bike left mister blake would you mind goingaway i'm boiling mad and i can't think thatthings i want to thank in mixed company or i can't leave a beautiful lady indistress here want to sign my carly self relianton just for no particular reason exceptthat i've got a grudge against my ecard you know i i think i'm gonna like you you know i doubt

any woman who's been married for fiveyears doesn't really want to meet me are you just want to play at me you want to choose to shoot some able onsome popcorn men run home shivering gratefully aboutwhat you almost did you're trying to tell me that europewill no i wouldn't say that because there is a bounty from mike held inwyoming the ride my culture as both up died downand i think it will because there's little ballantyne looking for me if we leave right now she can see it'sgoing to give her a national smiled as

we drive by what he said mister wolf i think you found thepassengers when the government there tony dialing forgive me i behaved atrocious strike now i wascurious about the cochran are laid off of a man i hardly know means nothing to me and something thatwe can tell you using good-looking i can't explain why

went with him except that he's got is like franksinatra i'm not worried about him i'm worried about losing valentine'saccount we'll show you drive away with blake andhe's her private property i wanted to get on that point beforethat ballantyne you know that's the bad and apologized for your actions thisevening i want this mess straightened out beforei lose that account is that

or you're losing there's not enough argued over their project like thisthat's up to you and this is the beginning of the end ofall that i couldn't discontented white business too uses valentine's we make it clear thatthe episode was innocent on your part and i were annexure never going to seethat man again uh... make this apology good don't worry about your commissions tony and after i levi hope you and your bankbook will be very happy together

mister blake a lightening barging inthere like this is a law office you gently mappings wrong where's my wife how should i know to look under the bed i don't get funny way receipt floriocanyon twenty canyon all kenyan you're the husband of the white i was out withlast night gaya as here then it just a minute ago or she was yes jim

she wanted a divorce divorce because of you well that may come later charm after allhow long can she resist these baby blue eyes but right now the lady just seem to beon happy she didn't like the cigarettes of whiskey bissell orvalentine's dog food helps you want to have a look aboutright she wanted a future before is widenedcarefree as the open rolled without a burma shave sign insight tounderstand what i mean sham by which you

wouldn't you calling me jump okay pal life kali i said on top is all but now i'mgoing to be quite do was anything else he said that we should be good enough towear on the table and stick to the worst reminder music tommy did she uh... perhaps suggest that i quit my job foryou wouldn't do that which referred i'm of attended the truth it might help out

that new bosses i figure woman by the hand climb to thetop of the hill and say focus although more he's a woman she's like itself i've got hold of her hand i'm not goingto let it go she's a skylark your approval maybe but i got a lot of spouse crazyabout but you give me an idea

just taken a closure but by the home until it is shows upuntil i've quit my job are you and why did the lady which you know i wouldn'twrite out if i were you pal all's fair in love and war charm and a lot i want to talk to kenyon dot order to tell them yourself the and i said you weren't expected home i didn't want to see you again where ihad to come home

hiatus is too late now but creek park job this morning hw craig stewardship even abercrombie soap now i'm scared connie look at me telephonic groans not much to tell him you of our lives would have to do it took a lot of so that i a busted rightinto the boss's office

the president of red cap cigarettes wasthen conference so i told him off course i said no wonder red cap cigarettes whenthe reader's digest taste test they taste like the reader's digest now the upper destroy cookbook at six twenty one and i said it was notsee here poorly awkwardly clark told me i would think it is do youthink it's the services had been always wonderful to know that you don'thave to go to the office in the morning or what that is i get

i think you have to go in the morningyouth you see although i guess i quit catalytically couple weeks to get thingsstraight around him on stanley you just can't leave all thepeople at thanks that would it be a i'll be back in a minute yesterday all hello missus valentine how do you dois risking it is there anything i can do for youplenty i'm not talking about today when you look at those iva skyline i decided to wait until they pick ablock house and they would have to say

but jim didn't they can you know what doyou know why uses valentine i'm trying to be is nice is i can't you but i'mmontreal on how the animal about don't think you realize who you aretalking to you know i i know i'm talking to him at all valentine mis course meat products of nineteenforty three an object out if you haven't i'm eddie i give the artist showcase athletes got hot buttons i hadthis afternoon we've all for your information tony quicklyadvertising agency today not get out of the year before our great dane takes abite out of you and gets his back on

time dot go dot that hello will held that w despite you know what is it you don't have to wait till we tell youthat one of the marquai itself what one at depicting yet again slowly privacyplayed like newark

house at exactly the right thing is toget to fight as on today in on the really and truly free all connie how does it make and i feel which you know as soon as it comes up ona microscope maybe system backed me we can fix it upplease what up man really couldn't get it to fire me as ofyesterday all open the door on chelmsford like jim boulet all that jim i wish you'd been unit willbe gullible why because with metal

valentines and chile calc i've just gottony fired as of today buyitnow women showed up some could we're doing hereanyway my pal i came up to see my client missuskenya malai uh... another client in the long again now that tony is quit his job is thatwho need for a divorce that remains to be seen them something is very enclosure in the stateof denmark when you mean by that caught your bosses telephone number

why do you want that to you but if i call it lost find out whetherreact we quit his job and i don't think he did well what mum it's long acre five nine nine seven go so i call and john malone decided onthat hope you don't have to call him you were lying to me tony you hadn't quit your job

everything you said was alive on on onon when i said i love you i meant by issue ought to shut up all paint job donate you didn't do anything except my alright highlight thank you jim forgetting here when youdid but just the usual blake service to comes up every divorce no extra fee parker after the divorce maybe i can give me alittle more unusual service after the divorce i'll probably wanted

dole and fact one of skyline starringalan dot slim western pasta and ginger rogers before we actually a word from our hostess lady este how long has it been since you have tojust nothing there without benefit of makeup and beingreally pleased with the attracting braille cared for appearance of yourskin utility lines in wrinkle shop aroundyour eyes and mouth

you seem to mention his own occasionalbig hole do you feel a little bumps or dangerscan have a dry salameh well perhaps you being too busy latelyto give you a skin care it needs and that you've been too tired at nightto follow and long drawn-out complicated beauty routine you thought was necessaryto keep your skin clean it's often youthful looking that's why more and more women thesedays as so enthusiastic about the new quick improved method of skin care the method because for just one cream tomake the skin looks smooth and fresh and

younger lady estate poor purpose face cream and many of them write me at this one cream silk weekend easy touse there's more to keep them looking theirbest and rb of a duty preparations that everused when you siesta face cream then just came for important aids tobeauty every time you smoothing on wipe it off

here's what it does it only cleans your skin second itself engine scheme leaves the dryness that may cause of thelines it helps nature refine the pores untimely it leaves a perfect nuns dickie base forpowder so don't let neglect give your skin that dry overlook

stock using a b_s_t_ for papa's facecream and remember is one green is all you need for the complete care ofyour skin mad and on active love skylark starring preston foster ginger rogersand alan justin activity other than the divorce in theworld should examine the leon and jim blake and she engender rapidly becoming acolumn asylum

went on a returned from a soldier insouth america the night on a ship docked lydia and germline navigating the diningand dancing as the scene opens yeah just returningto liddy is apartment has not happened goodnight jim uh... you've done better mountain that better

for bob dole dod although it couldn'thave been mad good imagine punch but our staff and turn on mywhites no thank you i can find a light switch very easily bythat delay mignon what united goodnight video you're kind of great media

tony get out if not on a now wait a minute are just got in from south america doyou call this a good neighbor policy if you don't leave immediately i'll callthe desk lydia mister bower says a man of thing istill love you the same as i always did i'm sorry tony who are so right about me i was wearingaround in a vacuum it's called competition you're trying to tell me they can'tchange it

no have reverted to type but i can't seem to like so much have you noticed my pangs last night even caught myself howling atthe moon i'm a little red riding hood jim blakewouldn't believe that do says that is my exhusband who shouldchange of use of the situation might have in your situation is veryinteresting positions are reversed and jim blake is now on the defensiverole that twenty canyon formerly

occupied on so you are trying to beoften when you're doing very well of course isthe end of the circumstance that i'm now jim wright you know you're a second undertaken yelland limited remain one of my independence independence nobody'sindependent no matter where you sit there somebody sitting one step by it there's always a mezzanine concealed changed a lot whereof anyway i want to take this

studied to our summer place on our own uh... writer one were to work with giveaways so what do anything you want whether that be agreat sale let u it's always more yours and mine anyway mention moses let's go up there are you trying to make him happy too irish treatment and go away

i still love you i can't imagine anything without you you cameraman i look at you were not see someone iused to know and long time ago itself known for clinton moving all the blueprints in hand who have dreams

pieces of the future we saw togethersetter the government even the etcetera in the u thank you for governors or fact whatever just how best to involuntary reflex it proves that i don't know that story ilike 'em normal notebook

mustn't forget live here it takes to make the forced us is a doesanything else tony g_m_ why do the two of you have to follow meevery place i go away because i love you but try to leave me alone on a kennedyat the end what do you boys think you are theandrews sisters i came up here to the up and get awayfrom the both of you some acted think things i'll calmlycellular the uh... what's that i think about you know i'm the only meant foryou i'll do anything for you

i'll even now are you i tried out some by try that some doesn't stick at least award now that i'm around i don't know what to do well i could not pinpoint a flower and iwouldn't have to worry about a mate bootlegger live a heck of a life of thatone of these around but let me uh... why don't we go awayi've got my boat coming up it'll be in the mornings he doesn't like boats

one-on-one when we were first night asyou get seasick on our honeymoon that i can understand on why don't you do your dino she wants toget rid of your panel who do you mean by that term you're coming back to spoilour plans for the future you're coming back to major unhappy as in that'salready yes so why don't you like a good sportjust go away in fact worry vanish into thin air if you've got that maybe i canget on someone else's sawyer man is that what you wanted it

and i'm sorry didn't know homeboy us both of you i hope you have a fine boat trip bolton cdi upon yes inside you really are second to listing sick pretending to

but please take me back to the islandalready changed course were heading back i know what i'm going to say is crueland and and all it's alright buddy i understand after all and i had five years to getyour feeling this way about him i wish i had a child chance to startagainst him from scratch ironsides and there's a dive end up and i'm going to head back out i guess this is it

kyun misses it you know it should be all over again once a sucker or was it sir now i can't help but are needed toalright i don't think i won't be back probably on your tenth anniversary you'll really be needing some legaladvice than i'd the bomb

thanks indeed all like turn your face is clean all you've done by tomorrow come back and by the news and we'll see hekmatyar camp something wrong anyoneheard nothing but mike and their pride or when puts us all about mind remote rocks too much video doesn't think it will stay in thelong journey so she's changed their mind change their mind

the did you do to me that we one-third at you and i will we won't bemr mrs canyon all over again view still written door i still want todoes more salim won an aspirin did mind that's what i call a romanticspeech don't no position to be criticizing myremaining speeches chum maybe but don't forget the positions ofrevised again remained yaar canyon again on the defensive and i'm blake once more back on the offense alright

you what's this defense of play really have come here now does break stand any chance in thisgame grown men are not aftermath kicked off does enjoy rogers preston foster anisland just length of the u_s_ most delightful half hour the lady estes greendale players werefortunate indeed and having your with us tonight it is our pleasure mister bradley

we know that the benefits from theseprograms support the motion picture refunds country homes and clinic an activity that is vitally important toour industry now before we tell you about next week'sprogram here's a word from one of america's bestknown beauty and parties lady esther implements ranjan these how long has it been since you metsomeone who said

how wonderful you are looking your appearance depend so much on thecondition of your scheme if you skin looks a little neglected it it seems to have lost some of itsfresh young sparkle people may think you're looking tiredeven a little older and it may just be your method of skincare that's to blame you don't need a lot of different beautypreparations to have a fresh lovely skin millions of women all over the countryuse just one cream maybe esther volker display screen

and i wish you could read the lettersthey write me so many of them say that may have toface cream helps make their skin look clear that this looked in years and likethe way expressions up asking clears away that grad tired look you'll be thrilled to when you tryeighty s to four papers they screen it can only cleans your scheme itself and your skin it helps nature refine the polls and itleaves a perfect mountains dickie base for powder

just try lady esther cream and see howsoon people start saying mild how wonderful you know it's too late lady astor screen guild players willpresent one of the plan is stories to come out of the war john steinbeck'sdramatic play a motion picture the monus none it will start civic pride with annlewis cole they showed a lesson gender rogers is soon to be seen in theparamount production lady in the dark preston foster concerned a c_n_n_ buti'll come out there in alan joslin

cannot be seen in heaven can wait both twentieth-century budget reductionsradio adaptation of tonight's program was freely based on samson repeal stillplay and alan stutz motion picture treatmentof skyline music on tonight's program was arranged and conducted by wilburmatch to help your government save ten i havea larger size all lady yesterday screen and at the same time you will saveyourself money to invest in war bonds and stamps releases truman rightlyspeaking polyester saying thank you and good night

rd heaviest represents springhill players hispaniola play tonight a major and a minor the styling players there's one ofaccident this is really applying and this is battling but clearly it's the adapted for radio from the paramountpicture of that name by edward carpenter and finish your work

it stars water baxter is major curbingwrote what i can see why applegate the minor and the diana limb of the originalmotion picture cast as lucy hill one when zoos and i'm linden graduated willnot have to be spelled everyone at school and became a professional heavy skelter she thought her troubles were over but on our first business called suethem and they were only beginning and they began with a quality awardnamed osbourne

what do you say you name was mentioned applegate citizen applique twelve missapplegate my wife and be back with several hours the one that's what value what code intoa drive martini uh... d they times i hear they give u_s_ galcayton and and that are don't be wiped out mister apple bottom well for you iffy

suffered a dime i'm not the only one we may end my only son polly at military school baat come on welfare not miss applegateruk place we're going to have a live twenty four along but i have a little by people and then a little while buckled miffedat odds that you live going to have a scalp massage heat through offer

outlook in its applegate i don't know how much influence i havewith happy scalp but i've been there but we could quiet but some years and i'venever been cleared this way before if i would point your added to an online iquit and right now i'm going back to stevens and iowa i still got the twentyseventh at the it takes to get on and i and bali close twenty-seven west on the grandcentral station almond twenty seven fifty one stevenson but there have been raised a very good

at first susan but she take a bus butthe bus lines were on strike fences and had a brilliant idea kit both of the child in by a half airticket hurrying into the restroom susan don theprobe bobby socks shortened address twist there have been to an adolescentmodel and then started back to the ticket window and what i had barricadedthe stevens and i a locked and boarded the plane when the conductor refuse to believethat susan was twelve and tried to put her off the train

she ran away prominent and hid in thefirst hand a compartment outcropping and uh... milligram are huh what's wrong with the new laws now don't worry i'm constantly for theirchildren player in the right congress to cutsixty four twenty the body of the loan back and i like iti get there hold not three even some iowa

military your divorce little girl hinman and sometimes it's over trying tolimit rather broad quite mature well i guess it's changing close i'd probably little boys fortunehim park him and he said i said they're not by me whether there is no mother and stevensand i a l what was your ticket obeyed batman talk that although theconductor land willing to the conductor and find out where you belong

i want idea uh... and that they cut i don't want thesesetting up on my agreement they called everything about safety right yes maybeif i got your head thank you apus environments clint relied on childquickly now make it back fifty-yard airport that's alright there's an upperknife hiring for the poor to make it a on full by not both a concept

himalayan you'd better have a greatwater repeal at what's your name bility and a commie anythin alright since two i'll make up the otherbut myself so so don't worry about the poor maybe i've got a call back ten and acollege gottfried hang back tell you what and mainland

nine mahmud unko by name is kirby major philip pippi like media but at just about this alive aside as an instructor militaryinstitute teaching the young idea to shoot like anita products all cleared up about that's like probably with your own orabroad are more than half of the offline that's what you think

and might on is awful me here well lit webmasters who don't call me major uh... have you got a nike with you sump pump fell suppose you it go and then get changed really think i shall not hahaha westech place at the end

and just sing out if you have anytrouble with your buttons haven't had any back internal power lineallies well well well twenty waiting for the anything wrong but if you system asap god willing to serve dot at do you keep saying the new and knowingyour army although i've got a bum i i i

give it a workout every morning that and and abundantly long here i uh... i didn't think it was noticeable but anyway it wouldn disabled me as faras regulations at this and i'm try to get transferred to military instituteselective service s but we've been washington trying to arrange it at the trace any mistake should bolnawhere we are being held up by over the water over a bridge or corporal on compress not back

incoming class we may be stuck it up aquite a while this time do you want to not fulfilled sosa europe survey sweet child that what would you like about this timebut get it and i'll bring it back fifty pc cokie he wouldn't let you have coffee uh... well helpful cute tops and i think that that's anappetite helicopters weapon

but i'll get you what i think a growingtraffic have no after breakfast we can play cod or check has a something i'dgladly top and explain something uh... named maybe that get theirthinking happened out of college simpson europe very peculiar try o youthat i am uh... and he'll come get me back at them i'll have to have the price by givinguh... a big surprise or a little surprised have bigcampground

you might even call in and around excepti did we're what about that yeah hinting at the european filtering walk parody here computer program appear on blog willlook at that time is especially when they're not forgetting on second thought the meeting

met mark on that i would not be notexcept that opposite unitech except a for the initial he came backsarolst he's not allowed the connected not supposed to know know why i met himi already thermo traveler of how to get on the strength to buriedabout and edit dilate so i go quite seven-mile two matters whether but stilla pattern of the time that i might go along the fella occupied accompanies theproblem was a matter of fact i had a very pleasant reply had picked up alittle girl it would make it pedi

how you can contact marlon warmer andprobably other are you referring to students who have been about anything but i'm trying to that moment welcomebachmann might how much he's just a child one i might be a a father i wouldn't doubtit out did not get out of my weight may twocad palaces and saying this is obvious accolade delayed highway doughnut untilyou've got some obstacle come back here at the back and fightlike a manual hit-and-run amazon okay

yes there is anything wrong or no system really just lovely i'm thinking that i was afraid whatever someone you see a pop-up i'vedone up to one month's time and i know achi yes it's over and i have been no streetapprove it all in fact one of the major and minorstarring diana lam group for nick and one of extreme before we hear act two

i was going to want to know the nametomlinson seated next to a woman we're going to a different one johnsonkeeping house as well that's a busy schedule and i said how doyou find time to keep yourself you can somehow be it'll probably surprise you she said aretaking better care of myself now than when i had a lot to stay in town i haveto my skin gets so much to do you know andbroke while it was beginning to get dr en route from the wonder why so much because it widening i have some of myfriends when they were doing kamensky in

and not found that many of the buildingthe levee schemes were using the eighty s department his face cream and that's when i began here she killedme and i think my skin looks my next well looking at least smooth cleanscheme you couldn't help but agree she was living proof that lady has defaulted his face creamcan do wonderful things for their skin even on the most trying conditions u_c_s_d_ face cream explore ways ofmonths to freshen beautify the scheme

academy cleans the scheme removes all the greeks and grime fromthe tiny core openings seconded softens the skin believes thegrants that may cause the lines it helps me chairman annapolis and four it leaves a perfect nuns dickie base forpartner just imagine one queen has only fourimportant things to your skin your bank this time your client you'll see why more and more busy lovelywomen everyday a-changing delaying he

has to pull out of his face cream put acomplete canada scheme plan donna and i was like in the of the majoron the managed are and what about stare as major philip caribbean both one a cast susan applegate and diana land as lucy pat at the major in israel as a family of all have discovered schism in the majorstrained abutment

susan had to accompany the major to themilitary ensued where he served as instructed the idea being to prove topamela and her father colonel hill but was the majors commanding officer thatsusan was not a young woman assembly a twelve-year-old girl whom the major havedepended and the idea worked best as an adolescent andover workingheard childish wasn't having to susan filled every adult indian studentbelieving she was a twelve-year-old but she didn't go pamela's little sisterlucy you see lucy was really twelve years oldand when she and susan where loaned her

room and any well you know yes that's it thing here dot eat danielle aloni bellatlantic daddy went deep indian wrapped the babytalk radio cannot twelve because you're acting likesix how old are you anyway twenty quite bad not for one will for

any conduct the ground that camp left me evaporate about lucy email i hope anduse it case those clothes don't belong to a twelve year old okay i give up we contacted my baby steps any longernot leave me alone well you have to have a lot please don'tgive me a wait-and-see man how are you getting getting a given we understand each other and phenom indicate

out of the cadet thank you for a week all right on well run at just about every one of myguests black workers who have found ten to fifteen xland you can call over everything and when the record and getting a budgetfifteen euros in her car legacy dr detail well i don't care whatyou read astrid obvi t thanks a lot of confusion but i canexplain all this very simply a well i didn't have the money to buyapple ticket home i had the right hand

so that's the reason for this kind ofthing never dreamed it would also not likethat ultimately does not believe me correctly i still don't understand why you didn'tgive me a way to your sister because she's a stinker denied here on our own right there how to smoke well thanks how about you

adolescence eighteen hours left withoutsmoking david next thing i know you're the other email hi paul why watson alcohol ranking againstmaking they are all kids out handy pureedpsyche lucy you may remove free a lot of wayward and here with some of your cover up forme that and i think it's time to meet a sneakout through a back door and beer i wish i could go myself anything to getaway from my sister you awfully pretty when she went afterme get credit was awful the watch

mail you will not let them agents on that level have been a bottom had not since i wouldbe speaking certified for a woman is sneaky is shallow itself job but i hadto say she's willing to go anywhere with him iceland's and then anywhere i suppose that's why she moved heavenand earth to make sure i didn't get transferred active service anything around back off california they have found at theconclusion jumper and jail cameras pick

out the husband she wanted to watch himright here in india as you can hear elephant may develop any got a bum ibuddies not stonewalling idea taro love is a very athletic commission yet but i wish i had a powerful friendin the water problem so don't worry i know washington senator one it might be a day deal may work against them right now we have to get your a prettyecr

needed the cadet corps sector that's what i like a bunch of mas aroundthe light bulb and remember when you're dealing withembryonic generals grafting and out there it depends on the acapella sir yes or so uh... how do i could hear i would beawfully gay nameplate taking a little tiny yes yes i've noticed that his went back toit

that's why i sent for you you want to take food noel synopsis or at el nino uh... did your mother motherof the pick up the subject of uh... no or i mean uh... as far as preparing you for or welded bearded anybody in your familyever read no though you see sue sue

when a girl letters i should say when or one point three sets of nature or what i mean here's have you everwatched balls did not like played well you know that when you put on a light onthe porch the way they come from all sides a lot of it they'd bang their heads against certainbump their wing we have created are not quite that reporter and writing i could see alighter correct marks mysteriously

nobody knows why when he just does all you can do is putup screens or him down the like yep and ali coincide don't throw me off some superhero well i mean it's a year's you wouldn'twant to be a light bulb would you a swarm of malls flapping out to himbreaking breaking their necks pestering you loud tell me that might find that was let out so soon do baker list sometimes like like paul

or voiced concern nobody's she's pretty like you over three hundred little more superschool well well they're all attracted another talks like that that dali b ordered these artwork for the groupmadan event didn't make it very clear caring you know social when i look at you adjust my bum ari

you look almost grown up like something on a sunday supplement because all run together a group ofglory not a child anymore keep looking that way like a reflection of the water with thewind blowing so soon some day soon you're going to bea knockout try to be a well behaved like bob uncle ho

earlier others see if that doesn't understand i have aminute only now i know what you thinkadolescents makes you nervous right are you doing bring about economic gain your augustit's going to be ten minutes to open it deck that federal offense stayed throughright now electro she distinct rally said she was here extra anniversaries married to an arnoldand shot

kirkpatrick just after fantasy there hasbeen turns down correct request for transfer active service that does not approve your point anyway i can bring this letter but that won't help the late-night the i've got mad why don't i call pamela's panic and thati'm pamela and ask a capital gains tax but i a priority really help i didn'tbut then went on the respondents say from architecture i'm practically bare

mark good and i was one we want to missapplegate at daniel wright here comes another mark war was still too had has when we come i love you dot com again wyoming andwalk down from new york orders at night watching a meet you you don't want to welcome to thecommandant albert our convoy which i did one store dot lights it's owner to

and you'll see is there anti let's address type haha well-timed where's the charming younglady you want me to make the season and telephone booth that popped make i wanted him to call it someone inwashington she's certainly but in a long long time and hope that it might happen then she ispart this is soooo so applegate cecil

this is populated etc to soar haven't i seen you somebody forward togoing ot hawkeye top pop accelerate and minute walk into a muscle when on but there's a definite we semblance tosomeone died just can't banker robot walk here comes a major kirby in israel the major bounces who want to play andas you stand on this hill unraveling ever seen a bball because he wins and ia lot but good evening good enough for

others play the heavy down here for avisit to get out of the children behaving yeah globally well i think but as i would just say needs to say wehave been so most liking resemblance to fill a white dot going to take a lot ofmoney what really well if you say so so so well head provided we body the nice boy has a little trouble with the cells de-rail miss tilly thank bill will yieldghastly have who or life a little bit

founder of the trade y f because for amoment i had a crazy idea hype what she would go with a bit of wavhated if you pardon the expression fled their platform a scalp massageplace in new york by the name of susan applegate how it pretty good susan applegate but given my son just say that thatcould you could meet major credit has a long distance call just came in fromwatching for you cooperated to all three per

this seventy eight elm street stevensand violent uh... there's served but little miss angela applegate uh... yet that she's not here in oz he school orgy of school there are noyou must be older sister resemblances right well concluded that in fact i at nearlyfifteen remarkable she told me that you have no brothers orsisters i major looked pretty how yes maybe itcould be active in

exited propping up to you here's what i have a message for a goodfriend of social ago they lose he asked me to come of it poem called to washington very effective my little yes the majors beentransferred to active service and uh... he did not marry lucy system mary pamela no travelgate

something crazy is popped into my mindthat brought this is a state of emergency president declared it was well miss applegate my train leaves inthirty nine minutes though i don't know anything about the laws here in ourworld but when the price of food about that you can get married in about an partnersr_u_ opposing communicable migrant lateral i would go go by proxy by mariosister i'll be very little impact making

because of course it would make sense tounpack will not know what i did that without arguments are i really don't believe that i can't waitfor some sort of grow up alan can you wait only until train time on top of our doesn't give a girl next time to makethe leap from childhood doesn't nobody i think sooo soooo could do it warehouse

now on not go philip but since you didn't the ban on land water baxter and ruthwarrick for bringing us the delightful story of a major in the mind of thisevening the lady astor screen guild players on aroll of guest stars gratefully adds your names damaged badly scene we know that thebenefits from these radio programs go to support that

county housing clinic in a motionpicture really fun jet of elected he today's most importantin our industry now bands well we tell you about next week'sprogram which is a real surprise i'd like you to hear word from one ofamerica's best known beauty your party's lady astor thank you miss clark how long has it been since you metsomeone who says hello there how wonderful you are looking

europeans depends so much on thecondition of your skin i mean if your skin looks a littleneglected and it seems to have lost some of theexpression young sparkle people may think you're looking for aminute even a little bit and it may only be a method of skin carethat's to blame now you don't need a lot of differentkinds of beauty preparations to have a fraction of a scam more mature women all over the countryuse just one cream many esteem for purpose they scream

and i wish you could read some of theland as they like me so many of them say maybe has to facecream helps make then skin looked younger fresher than it looked in years they said they normally to accept thisin it's made of that john and time's up you will be thrilled to with the firsttime you use maybe a supporter of his face cream it thoroughly cleans your skin itself in just one

can help nature of the time of course and it means that they think nuns dickiebase for powder just run a t s to forfeit his face creamand see how some people start saying mind how wonderful you know turner the lady astor screen guild playersrepresent a real surprise radio program it's one of the finest musical picturesever made both of the blues it will start johnny mercer jenny sims and then crossing days yourlist

one of action there will soon be seen inlady in the dark panel and then suddenly seen in the miracle of markets three polpot paramount productions group warning and soon be seen in the uk haleproduction the iron major music and arts program was arranged and conducted bywill revenge to help your government save ten byabout a larger size not lady astor face cream and at the same time he will saveyourself money to invest in war bonds and stamps missus truman rightlyspeaking for lady astor saying thank you and good night god