Articles

Dr. Heather Gladwell: Skin & Soft Tissue Infections in the ED

September 27, 2019


My name is Heather and I’m gonna talk about skin and soft tissue infections in the emergency department. And that’s obviously a huge topic that I can’t possibly cover
all of, so I chose some very specific objectives that I’m gonna cover based
on some cases that I saw and I’d also like to thank Dr. John for joining us He’s a medical microbiologist and the
medical director of infection control and so hopefully he can answer questions
people have about local antibiotic resistance and antibiotic choices so the last four weeks I spent on HULC and on HULC you do plastic surgery call, so I saw a lot of soft-tissue infections on
plastic surgery call, and it left me with a lot of questions about what we do because there’s some differing opinions from our point and the surgery standpoint regarding antibiotics. I want to talk with diagnosis of
abscesses. MRSA coverage for purulent skin and soft-tissue infections antibiotics after I & D primary organisms causing cellulitis and the role of Ceftriaxone in treating moderate to severe cellulitis so the first case I’m going to talk about is a call I got from the community about a twenty five-year-old male who
presented complaining of left arm pain and he admitted to injecting crystal meth
into his forearm and thinks he might have missed and he had – from what the Emerg doc told me – a large area of erythema and swelling on his left forearm The Emerg doc then texted me a picture to
show me what he meant and I ‘ll show you that in a minute the community ER doc did a point of care ultrasound to confirm presence of an access in that guy’s forearm how many call that’s because he thought
that the assets that he did see was really deep and he didn’t want to
operate in top condition might benefit from who are so this is that the tree something and he was right we ended up getting
formal ultrasound and i cry and once you are for uh… and watched it but it made me wonder how much better if carol chase down ben
our own clinical exam when it comes to diagnosing abscesses and that’s actually a few papers at
their but this time we can talk about two of them so this was our prospective study done
in california on a hundred thirty-five patients in academic to hospital and they included any patients with a
chief complaint of cellulase are assets that have to be accurate sizing up the
feeling unsafe and they can use oral sex uh… and the residents and stopper
provided with thirty minutes about some training tonight for a very between study some
times it was as little as fifty minutes sometimes it wasn’t really a formal
training period and uh… they use the linear probe when i was acting jones urgent care at micron uh… to use on that upsets benefits they’re not buy it anyways this is that what the uh…
defined as an abscess on ultrasound so ananda collect or hydrochloric structure with poorly defined borders it’s usually
spherical in shape all about uh… okay soul poorly defined borders usually here
comes the although it doesn’t have to be there it will not internal apples and then this is an example of what
they’re looking for foresight latest and not smart primarily by koppel stoning so that we have a steady work is that
they were ordered to yes or no assessment of an abscess after their history and physical exam and then they get their own point of
character sounds it wasn’t like that and then they were recorded a revised
castano a passion all the patients with a free ultrasound
assessment out yes i did find do you or needle aspiration uh… patience with the pre on south
africa no was up to physician proper and so after
they get their ultrasonic make a decision about what they wanted to do
you think about how the patient followed up at the base by phone district them
with their patients products or they could you an idea of
illustration if they chose to him and these were the results system or miss priestly clinical exam
was actually fairly sensitive or outside so eighty six percent just pretty good i think the specificity
was a little bit lower at seventy percent and now when you add a point carol chase
down into the picture hymie subjectivity went up to ninety
percent in specificity of eighty eight percent so much better uh… so in this study point carrollton
did increase the diagnostic accuracy protection about substance and in cases where ultrasound disagreed
with the physical exam uh… ultrasounds correct ninety four
percent of the time thank a good example of that was ibiza
one-off case that they are reported but one patient had a growing but it’s not a
growing up there so they put the ultrasound probe on an oxygen tent
yesterday lingers on so not having to drink because a supple sometime motion and
lack of internal echoes so i mean this was sent out of one but
it’s a disappointing where option could be useful twenty seven pieces we lost the plot i
think about the function of this been kinda marginalized population a lot
of didn’t have a phone number to follow up uh… there was no whining as i said and we don’t really know what happened
to the patient-doctor variety because after no winding up sorry
because they were followed up by foam show i mean you’re relying on occasion to
tell you whether or not they’re obsessed with solves they weren’t didn’t were subjected to repeat physical
exam rope sound obviously would have been accurately
sound to heidi patients who had a negative clinical assessment in a
negative ultrasound so they were sort of stock with that is
there cocom and also um… ultrasound picked up a lot abscesses that or question of the clinton significance
though one of them was happens the sea so i don’t know what i mean not could
have potentially responded to truck salam but it was trained and this is the second saying he’s gonna
talk about it very briefly because it’s very similar to the first study but said they focused a little more
patients but that clinical fail a dozen no obvious that collection and in this study point carol chan
change management fifty six percent of the cases solan some republicans and it’s actually
pretty sensitive process detection you’re pretty good job com without ultrasound without a sound mixer clinical diagnosis
batter and that doesn’t say anything about
picking up on the weather makes the snow comes back and say that but uh… it does make our clinical diagnosis better so maybe the patients for whom this way really provide about that would be
people who work in a follow up so mark’s wife populations citations i_v_ drug users homeless
people it might be a benefit to know right off
the bat what you’re dealing with ’cause if they get worse they may not come back one of the second back questions i have
a back piece was uh… whether or not by always needed
here a camera say coverage for a cure-all in skin infections there’s actually a lot of studies i’m terrible at their site shows that
she had to talk about briefly uh… one was in the new england journal message
without one because it’s very comprehensive uh… and then the second one it shows
because it was done here in london so it probably has a lot of implications for our local practice in uh… sensitivities here the in internal medicine study with a
prospective prevalence study of adults consumption factions and they looked at
time of america to department eleven u_s_ cities excluded all terry rectal abscesses and swath of all the cure-all insights
were culture you can see that makes example than ever
say access there on four hundred and twenty-two patients
were enrolled and i say with a sladana fifty nine
percent of their one copters is pretty high only seven percent of the
estimates were streptococcal uh… interestingly only twenty seven
percent of patience you came back positive graham marcie and their wounds
have risk factors for hospital acquired anorexic and that’s that that was a clinical uh… diagnosis so these people i’m happy absence of state uh… a hospital mission in the past year or
being on dialysis or how you’re going for you know things that you would
associate with probably hospital choir demonstrate and ninety nine percent of the n_r_c_ by
mercy street when they did you know taking or characteristic of
community-acquired on the menu telemedicine study a
hundred-percent respectable susceptible to subtract and ninety-five tyler susceptible to
kinda makes about as we’re gonna talk about in a minute that’s actually a little bit different in london fifty seven percent of haitians without
mercy infection dot its products with no emerson coverage lucky no different than cocom between
people who had and i think that sent huber heights at and rock recovered at my favorite is
those that that may be an argument for saying that
for a lot of patient i_d_ along with probably sufficient to maybe not if
needed antibiotics anyway and that’s of finding that’s been substantiated and other students as well so i guess that that articles that is
comprehensive but it doesn’t really tell us around about ever since he was optician
factions here uh… resistance house geographic
variations on the bacteria makeup dozens also i looked at the study is licensed under and this is just published this past
year so i’m sure a lot you probably heard
about this study before so i’m not gonna spend too long on it but some was a prospective observation a study of
the chief complaint of skinner soft-tissue infection three academic
emerges in london and they excluded and the small number
of patients that had uh… abscesses that would be associated
with different kinds of bacteria so they included things everything from
site latest too uh… accesses to ulcers uh… in baltimore md five patients and
they did two things they define connotation
and infections connotation with people who had uh… nair serpro culture for
embarrassing and then infection was silent infection sites
coptic progress there and the film dimension of uh…
predictor variables associated with a mercy infection and holidays nation wage there’s a bit overlap there but and summary incarceration in the past
year known exposure generously competitive
sports homelessness and previous access in the past year uh… were associate with uh… rustic
condensation or action uh… and become a m arce was the only
orchid deflated and twenty two percent cure-all
instance optician factions uh… but overall the seventeen percent
a peaceful kaunas or infected with hiv icing acquitted him um seven one percent of the patients
without marseille had community-acquired n_r_c_’s that means that since the
prospectus for hospital acquired at marseilles subclinical i’d i’d also sent eighty two percent of
the addressee ice let’s stop by gina taking or characteristic of community
park and here are hundred-percent again were
susceptible to spectra damp and cold but only seven five percent versus
applicant bison uh… bell seventy percent patients without our stake out its products and
glamorous coverage but as a doctor that with the new england
comments and study at those if they were assets is that doctoring it might not be
that much of a difference for some of them so buy my ticket for those two studies
is that a mercy is responsible for a lot of grievance consumption factions and
promise im not regular ones as well but most of our citizens optician
buttons on the people of any risk factors so it’s been hard to decide who more
interesting coverage it doesn’t i think that the bottom line is that
empirical mercy coverage should be considered and most dream consumption patterns the last question that i had it at that
particular patient was whether or not we e_t_’s xbox whereabouts asap ranking i’m gonna talk about some the uh… a study that would be a bunch of things
and then i think they came out of the same here that was not written included in the
studies so so any else emergency medicine and they
looked at six thirty a son three or six years and and of your
cities one had not liking officially over when only bought fifty patients and one had patients to as part of their
treatment got half lax by fifty-two percent absences grammar say-so uh… it’s been a vote limitation study i guess and then three a cohort
studies uh… and other three basically all of them found that there
was no difference in resolution after hiding for an infection traditions
getting antibiotics to expand our a c is resisting races with two experts is susceptible which would imply that sam it doesn’t really matter wouldn’t treat
them so and also it stays there is no
different in resolution print products personal enterprise or and rocks that were effective against
infection after him but that doesn’t answer a lot of
questions so begin keys out who had overlying
slightly this big event what if we tried to treat patients with a product summers is
susceptible to without include her success rate improve search that success rates so this study looked at bats uh… okay nothing here so as a retrospective cohort study of
community-acquired addresses consumption actions done in arkansas they only
included patients and their study you culture positive for uh… included everything from closer
buffet latest europe’s crisis excluded anything really minor likened
the taiko a mix of anything major with an
underlying disorder like osteomyelitis and they define treatment failure as
infection worst thing after two days in greater than one of requiring a second i
n t hospital admission and use guns optician faction or microbiological earlier which was culture of them are safe from a wound
after they completed antibiotics they’re on time zero from whether to day started with the
time at which c_i_d_ was performed for most of them but twenty percent of the patients
didn’t get ninety so that time zero was when there will be sculpture so they could set eighty percent had a
ninety there’d be field and five percent of the
activity by a group in thirteen percent of the united inspected which was a significant so active in charge for antibiotic sam about how to activity against them so it’s a despot reading and i say
accessing with antibiotics after redeeming current treatment failure but twenty percent in getting ninety i guess the bottom line is that and i
say offices may benefit antibiotics but there’s been no large randomized
double-blind placebo-controlled trial done so it’s really still up to a clinical pulses one of those slightly which is always the request do you know what field i don’t want and i don’t think it’s set
in in the safe zone recall reading so i don’t know the answer so the second case that sound and at rocketmail wednesday i helped me thirty nine-year-old mail them he presented to community emerge complaining about
brad and people attacked the past three days and sounds kinda like the last
night no-show associated with that here even on a patient’s attract some
for three days in the community uh… stab route still feels unwell is there a team of spreading and this is what it looked like so you can see the different lines where
people are kind of dog things over the past few days and continues to spread
beyond borders and that made me question um… in this
era community-acquired i must say uh… are we still looking at the same
bacteria causing diffuse non-political slightly this and there’s two studies
that have come out recently looking up at well review and the studies sick so uh… this size study looked at the role of
the day he would extra causing if he’s not culture posts lately smacking stark
two years ago scissor prospective study at a
california uh… county hospital and they had to nine forty patients with
diffuse an on-call triple slightly events so not associated with some kind of he
really important that you could culture on the excluded people you had uh…
here neal carryover orbital agreed locations anybody you could have had an
opportunistic infection like nature people future pena uh… different bugs involved so animal or
human bodies underlying uh… uh… disorder only cost you my latest and they also excluded people that have
at soft-tissue infection warfarin tightness in the past year because the way that they determined he would
have been telling elects rapids by doing serology is so that would have
potentially interfered with uh… and the way that they figured out who
had which organisms and on culture ble
slightly this was a bit of around that way so they looked at and t streptomycin always partisan in tds p antibody is
measured at baseline and then to the topics leader so if yes all measures um… uh… those antibodies are antibodies to
group a strep groups he struck a group ki strap and a_t_p_ are antibodies to complete cell they also um… sorry should say that um… typically
infection your add traders should rise within the
to meet and start to decline two three six months later so it should be parent
who has an infection because they’re yet to be a certain amount of rise and then
they should be about the upper limit of normal for adults on the second tighter uh… and only two to five percent of
normal adult about tigers over the number that day uh… how the store permanent normal they also are a look at what cultures
what kind of capture the people who had group b_ strep because they weren’t using uh… antibodies that could but the crew constructed so their secondary outcome was looking at
response to beat a lock uh… now with a high-stakes testing
clinical improvement after greater than forty eight hours to treat them bikes at sorry there so the physicians were asked to use
gram-positive they lacked camps for the most part b complied with that so uh… more stations eighty three percent
were treated with sap is all in uh… most of the rest were treated with
oxox ellen and then a handful of patience toppings
like antes up track some opulent uh… picked hazel uh… dot response to be lack tams could only be done because they weren’t determining
without what treatment so that response could only be measured in people who
were not covered for accuracy they only measured response to be
talking to people who’ve gotten one dogs or less i’ve ever read say covering it
biotic so they could get one two oh seven am i say active antibiotic in the
emergency department about the senate so there was tampering efficient schools and sixty nine cases had to be dropped and they couldn’t be assessed for every
piece of religion because they were lost to follow-up so they might have completed their
initial hospital stay in forty eight hours or whatever so they could be
assessed for being a lot to respond to that because they never showed up to get
the repeat serology done we don’t know what they were infected with comes to a hundred and uh… soni nine
people how to complete a violation and i turned thirty one of those were
positive for being with stratton so everybody was has us from a collector
response but they had to drop a significant number of people who were on
a valuable because some they got less than forty eight hours of june and i
need a lot kami or discharged early uh… or they got more than a dozen each
product of my state so you can see that the people who actually uh… worries that serbia lack of
response largely it was successful serb were very
few treatment gillis even in the group that wasn’t positive for beating elixir but there were a lot of other valuable
haitians cell at the end down seventy three
percent percentage in tel aviv inlex japan faction and ninety six percent responded to new
york times successfully i mean not includes the group of people accept
negative there’s obviously some issues um… with interpretation of this study so posit serology does include cortex and
so some east and purchase could’ve been nam point microbial there was a very large and a valuable
group of patients and i don’t know dr dot correct me if
i’m wrong but i don’t think that serology doesn’t that serology doesn’t necessarily mean
that infections of a cut they beat you extrapolate is caused by something else
that has provided a portal of entry in the skin orbiting with extra maybe that wasn’t the original pathogen so even in the air up to be a part of
our sleeping kuelen except maybe still the most common cause and if he’s not
culture bles like this this is a study that came out seeing
here with kind of a conflicting point of view and uh… this is a systematic review of these
judges say latest within tax kids economist similar group of people uh… and they look at studies that had you
think a lot for easter punch biopsy to try to culture uh… people say latest where there
wasn’t anything that was cultura ball so big and excluded similar people’s so
ocular oh dont genic armed factions anything deep tissue are involving
another organ which they defined as a processor osteomyelitis things that were thought to be
contaminants like stop at the terminus works for that uh… man anything involving the skin
break was excluded this fall so in the and they were left with eight
hundred any patients and total from sixteen articles two hundred and twenty seven have
positive cultures sixty five of which grew south korea’s thirty-five group group a strep are very small number grew other id he
lets wrap the most common utility celia is in this study
was actually south koreans however most cultures yielded no
organising so vast majority yielded an organism so maybe the real culprit is just more
difficult to obtain holzer some of the studies were altered so who can really make any comments about proportion of them that were immensely
because it was before about proportion would have been higher i think that the bottom line is that
even if they ripped me apart ever say probably most oncall terrible slightly
still cause they amass a single they strap select what they suggested that those
articles is to start with the data locked him in the drug coverage if
treatment failure at two days uh… adhesion st peters allergic to be
a lot of times could maybe just start with um… and on my sin since that has some some anorexic
coverage i guess another approach is to treat
people with breast actors are does more that we can ill treatment abroad in
their coverage berkeley uh… again what’s the threat research
day wendy and he was talking about uh… i his research of votes are factors
independently associated with treatment failure which included are fever tree arse leg ulcers idea marilyn to demand a prior sale
latest from the same area so i guess that’s another approach that
we could do philosopher snack when some whether or
not uh… subtract them is a good choice for moderate to severe slightly it’s kinda hard questions and sorry
because there’s no i i couldn’t find any studies directly assessing its efficacy
in adults and for those of you that had gone down hope he’ll know that our surgical colleagues don’t really agree
with our use of soft rap song because it doesn’t um… gram-positive properties omitted third-generation cephalosporins selfridge generations of course what i
can suck theoretically should have better grandpa’s of coverage so that’s why i wanted to look into this if the majority of slightly toasted
stock left that meeting lets up and i must say that might make more sense to
choose something with better gram-positive coverage but us again talk about it clinically that’s not really how it
turns out this was done a century uh… into microbial
surveillance program uh… study and i looked at about twelve
thousand strains of stop instruct that were obtained and canada and the u_s_
and then it tested their sensitivity to suck tracks
on a twelve other dynamics food pretty big undertaking is that samples price awaited from a
bright someplace is unfortunately not to skin to cry take that into account to guess and then they looked at susceptibility
in vitro so almost a hundred percent of the
analytics japanese study was susceptible to subtract some only sixty percent of staph aureus some of which would’ve been a marseille
society but for those present grinding fifty three percent of coed negative
stuff for example stop epidermis and that about ninety percent of
irritants kirk streptococcal which i think is a pretty low-key real instead organism for most people who are not suppressed so we’d be just as a w doesn’t
necessarily translate to review wasn’t numbers might actually be lower in
people uh… both amethyst anniversary strange for
houston we wouldn’t expect separate happening actually got something not all organism lives will be
necessarily representative of those found in assets to be honest i care
because they were cultured from a variety of different places in-vitro um… there’s a there’s a few different studies that
look at and suffering compared to such try out
some in a clinical setting romantic this one just as it was the
most recent that i could find and they compare diane subplots program
and said to you uh… its attacks on plus placebo mistreatment of water to their site
latest nipples this is a randomized double-blind
equivalence trial on a hundred and thirty four pieces moderate to severe
slightly this an australian and uh… they define their saline says
recent off onset soft-tissue working now with more than one of pain swelling limp and janice fever and all
three shin with her with a discharge c excluded patients that could diskette oral antibiotics in the
community treating physician i’m anne nosocomial infections were
excluded anne patients there were really sick
works great if the septic shock back to me on tom again mixed with aussie my latest anne patients socially unsuitable for
home treatment works for them as well and patients without kidney or liver um so they were handed my station sts
you hands up two dash eighty plus propensity cramped yelp or subtract
sonogram ivy plus placebo yell answer ends up taxing i think one is yellow and when it’s
clear i can’t remember which fights back and he said look at seated around the
banks of i_d_ solution too high ground and then they gave people
pills that looked like carpentersent and their hijab two points at which they
assessed work you work uh… at the end of i_b_p_ repeat your
was defined as resolution of signs and symptoms needing no way to bright
therapy or world fear appealable and then they have reassess them in a
one-month all of the set and here was to find a snowbird parents
at the same thing so eighteen cases were considered and
determine and that those were mostly people uh… you actually had exclusion
criteria but can become apparent until later so they had an underlying often my
letters or their true diagnosis with d_d_t_ they were never expected to begin
with three patients were lost to follow-up so at the end of the day i didn’t
thirteen cases were acquitted there when the problem here at the end of their people ninety six percent this of trucks and grouping eighty six
percent of the answer i was not significant difference between
the two thank your at one month was very
somewhere again not stupid the very same so i guess the study was assigned to the
first republican sarcasm absent a can suck not so much d efficacy except wrexham per se it’s not a canadian study writers that might not represent our bonds and resistance starbucks and i wasn’t really sure got this was that isn’t that i’ve seen that have
been entertaining care for example maybe catholic three
doses buy these products mimicking transition to peel but the average on mean number of doses
in inseparably seven of the setbacks in six seemed like a lot me uh… it’s not really clear whether
absences for so this is um… one of the say sit down looking
adaptations of tracks on the internet for selling us not in adults like i said i could end can find one but the study was done in montreal on treating kids as in patients with us
construction factions using such craft some uh… peachtree tickets with moderate to
severe slightly dismayed to find that was the treating physician thought that
they required antibiotics idly in the emergency department excluded any really sick kids talk to
kids immune suppressed kids uh… kids with any significant
comorbidity works with it kids away five unusual bugs so he will
bites were excluded anything really rapidly progressing
threefold was maybe not appropriate for a patient
management was excluded as well so uh… these contracts have tractable and if they’re panel urgent pickup
clindamycin very fewer than actually ended up
getting commitments most of them concept back from and then they were stepped down to
kaplan spiel unicef track some group and once they were not backgrounds
lately has had decreased by seventy five percent or their stepped on the claim that he
only planned the group and i was just a position description that was rightly unspecific and points that they were
looking for most of them got ended up going to stop
at some condemning son and it’s only nine percent of them were
successfully discharge from the day treatment center after three days of
therapy i could onto killing two products and hope there was a period of twenty one percent uh… so by failure i mean they were
ended up being admitted to hospital but job only twelve percent of the total uh… hot uncalled who uncomplicated
slightly city of st so dress for all the data for other
issues and you can see that honesty impl so they revolution was deemed
unsatisfactory active teachers center there are the ones that that field okay to mention a slightly misleading
going on for tracks and i have to be a plan etc um… that a lot of the others feel for
other reasons sam parental capacity to comply with teaching here roundtrip day treatment center treatment uh… or
they had an upset that had to be dream uh… other medical issues they needed
to be a good or thank ab obviously kids might harbor different bacteria
then it all some adults may be more likely to happen i’d say so it’s hard to make generalizations i
think from the steady two adult population
necessarily there might be a lower threshold making
two day i think it’s a hospital because they’re feeling terribly than it
would be for adults it was hard for me driving conclusions
from the literature that was available at their i think some treatment failures are
really inevitable no matter what we used uh… but it should be noted that none
of the kids and how much else study had about it calms the ones that failed
management and end up being hospitalized their oldest church you have no a long time morbidity as a result according to the study although they installed the mob for for very long so we don’t really how to better
alternative i think because uh… it’s been shown that’s excellent with the
program is this probably quibble interceptor some really draw from that uh… so in summary quaker ultrasound improves diagnosis of
access is in the emergency department uh… empirical mercy coverage should be
considered most cure-all instance optician actions uh… the land in starting an showed an arson is a soap opera turning
twenty two percent the back uh… that included some cultured cellulitis withheld access that wasn’t
really sure what that meant but sam the rate of and i’ve seen on three oh
one slightly sick on cultural sorry latest it’s not really known in london
so i can’t really making comments about that it’s not really clear whether absences
benefit for me to right after my deep and uh… such acts in a similar rates of
treatment failure himself you know patient management sleepless elected colin susan wilson says covers replace these in particular issue answer fish explicitly hdv interests canada he requested to see if the dates last night obviously the resume he serrated do you think he goes he said the study looked at the statistics
models calls it’s explode this whitehead diffusive relaxes lost lucid used for this trip cancels sweets where six juice this is the whole interest grandpas and add to your suppliers he into passive passive dr that for yes sir resisted explicit fractions periods in history slide exit activities since sister v it’s use the it’s yours dividend slides moves belongs st services this is the mesquite sequences i think so so so that i ask you izetbegovic or tutsi fuse net systems to you it’s true the group hopes that you have my cc user haha uh… you know with is sister the safe yes yes says the motivation for me augments attracts costello and you know so that cost-benefit signaling that and save
plus for and sadistic sos expensive imaginative transit bases said these so inductive foods maze uh… mutual xd you know i realized that me solicited silvester martha’s speeds glass so the only issue creating consistent that if you see the results me sob sob prostitutes interview
messages would be good you know that the sentiments of carries
the step towards them at c of sister words that you had a said black schools
wired wasted you’ve sold if you would exit polls is the posters that were this is a skinhead local said which states that sneakers difficult supposing id extended painful certificate it’s was one mayhew uses a street is now a state on it’s possible taxes cut uh… stratosphere all you know minnesotans because i’m really obviously oxley user any
intravenously specific clindamycin instead waltzes witness ast also will want useful equine aren’t safe stocks da society explain punitive leading to
the marks a hospital and he by marxists concede this uh… sold so who knows the head occasionally enormously unanimously by it and psych like this residency genetic counselor of constants dot com pat or as you know note you know i think i think one of
these white sources so they are it gets is odd urgency the we’ll see begins suitable you know i think keep probably romantic basically yet used eight actually i i don’t know the key point of being recognised boxes
that they should stay at the bottom concentrations of it sixty percent sold so thats with you exit with programs that one sixty stat and stand so that’s what’s up last teased sps but you don’t want to get this done advances jeeps it’s rubenstein inside there is anything that’s review decline stated here sastry actors and that detail research comedy no not an attack the entire he had i have in mind american like more more and the same com what’s what’s the himself your dad closest blood on they don’t get division activities is x it inspired boxes there is a specific them me no black decides for example thick expected bacteria said those here’s what or both c it falls down hear it yourself the way assisting detective out the act it’s exp uh… i i i do that delisting was boasts of the places
that us trees matching tee we’re talking about cost happy whenever there c act costing seagram some acrobats hello yet see people roa culmination i give us plots one step further uh… itself that’s more restraint
rigorously purely private schools or what’s that uh… that’s it the this address the say forms suggests that today except sold you know infinite like yes i suppose it depends a little bit on
that stay we with these people picture faces with that safety he said the indians stages yugos wuxi students all speak prevalence of often departments a patient’s presented him was himself the shakers i think overestimate said don’t if that doctor said that you
should be listed israel did fixed incomes this really over this said said with a lot of this investigation and so that’s good solely s three stiff slots but what we had yet allstate the state said we’ve too students is there a difference between said student must solos sold lead at least spoke he says aid close you know so i thing with c_e_o_’s speech you know cities but critics say currencies young you get the case p you know what you need sixty go overseas which cause steve x just and the number parts as he had exploited almost you know reusable ups fifteen times usage jobs muscat doha clindamycin excessive his population and you are you lights suspected coordinates involves the forster survives there when something comes back after six
hours later what works interest readers you’ll field of something different uh… but i think that’s what it is
addressed certain items that perhaps a plus a
really good puede la was might the impact structure keeps petitions cellulitis viewership courses i mean you know about but first withdrawals these page flight things better for you the long you know spots you know those court what we saw ancestral you’d sp here you can’t gains emeralds kidney that comes will well you that’s here dresses the most common uh… bhalo it’s it pretty heavily promoted often must with insists so if you see keep it suggests that he says the accessory they’re often gave gender bias loyalty melissa frequent flier in the hospital pacifism style you know i think she had a another collapse explicit really can’t went to the bases give instead last stand bestiality yes with a lot she was uh… each useful and exo you still do that teaching black population eggplant on c children colds people’s to start ones as first right a program like that i mean is there any if you don’t detrimental he is weekdays on that out but it’s greatly expand nato pencil disgraceful club so uh… you know a hostile act left alone is not available yeah i think that the next general stat is uh… flamboyant seasons s and i said and certainly older patients your pictures v t eight years old uh… access that still from your thoughts with us heated sian youthful on his whole life against it it’s twenty years you know it’s it’s it’s interesting you don’t need the estate auxiliary unit
will be recollects unified stands for uh… on everyone gets fewer one cases said chick screens cheese but it’s interesting but when i look at the excel databases locations names but one experts these days ngo i think that written and sydney’s i think you need to be warm patients c issued the this

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