Newsy Obok slidera Owrzodzenia

Owrzodzenia i zmiany martwicze palców powikłaniami zespołu Raynauda. Jakie są objawy i na czym polega leczenie?

Ten tekst przeczytasz w 4 min.

W przebiegu zespołu Raynauda dochodzi do powtarzających się nagłych skurczów naczyń obwodowych palców. Skutkuje to kolejno zblednięciem, zasinieniem i zaczerwienieniem skóry. U osób cierpiących na to schorzenie na opuszkach palców mogą rozwinąć się owrzodzenia i zgorzel.

Objaw Raynauda dotyka około 3-5 proc. populacji. Częściej występuje u kobiet niż u mężczyzn. Wyróżnia się dwa rodzaje tego schorzenia. Odmiana pierwotna, inaczej choroba Raynauda, stanowi około 80 proc. wszystkich przypadków. Jej etiologia nie jest znana. Postać wtórna, inaczej zespół Raynauda, towarzyszy schorzeniom, w przebiegu których dochodzi do zaburzeń ukrwienia. Charakteryzuje ją także większa bolesność i nasilenie objawów.

Przyczyny zespołu Raynauda

Do najczęstszych przyczyn zespołu Raynauda należą układowe choroby tkanki łącznej, w tym przede wszystkim twardzina układowa. W przebiegu tego schorzenia dochodzi do włóknienia skóry i zajęcia drobnych naczyń krwionośnych, które ulegają zwężeniu. W konsekwencji dochodzi do ograniczenia przepływu krwi.

Zespół Raynauda występuje również w u osób cierpiących na choroby tętnic, np. miażdżycę, w przebiegu której dochodzi do zmian patologicznych w obrębie mikrokrążenia. Może też towarzyszyć chorobie Buergera, która objawia się stopniowym zwężeniem i zamknięciem naczyń krwionośnych.

Objaw Raynauda towarzyszy również chorobom układu nerwowego, np. zespołowi cieśni nadgarstka. U osób cierpiących na tę neuropatię dochodzi do zaburzeń ukrwienia nerwu pośrodkowego. Zespół Raynauda pojawia się także w u osób cierpiących na schorzenia przebiegające z nadmierną lepkością krwi, np. chłoniaka czy chorobę zakrzepowo-zatorową.

Na wystąpienie zespołu Raynauda szczególnie narażone są także osoby przyjmujące takie leki jak m.in. chemioterapeutyki, estrogeny i nieselektywne beta-adrenolityki.

Czynnikiem zwiększającym ryzyko wystąpienia zespołu Raynauda jest również palenie papierosów. Nikotyna powoduje zwężenie naczyń krwionośnych, co skutkuje zmniejszonym przepływem krwi do skóry.

Objawy zespołu Raynauda

Zespół Raynauda w przeważającej liczbie przypadków dotyczy palców dłoni. Tylko u ok. 5 proc. pacjentów zmiany obejmują również okolice palców stóp. W bardzo rzadkich przypadkach zmiany chorobowe występują także na nosie, wargach, małżowinach usznych, języku i brodawkach sutkowych.

Do napadu zespołu Raynauda może dojść pod wpływem m.in. zimna lub stresu. Niekiedy czynnik prowokujący wystąpienie epizodu nie jest znany.

U chorego wskutek nagłego skurczu naczyń krwionośnych dochodzi do zblednięcia palców. Pacjent doświadcza uczucia mrowienia. Następnie w wyniku skumulowania się odtlenowanej krwi palce stają się sine, czemu towarzyszą objawy takie jak drętwienie i ból. Później dochodzi do gwałtownego rozszerzenia naczyń krwionośnych. W konsekwencji skóra staje się zaczerwieniona i ucieplona. Pojawia się także uczucie pieczenia.

U niektórych pacjentów epizod ogranicza się jedynie do zblednięcia i zasinienia albo zasinienia i zaczerwienienia.

Zmiany skórne są wyraźnie odgraniczone od obszaru nieobjętego procesem chorobowym. Mogą być zarówno asymetryczne, jak i symetryczne.

Zazwyczaj objawy ustępują po upływie od kilku do 20 minut. U niektórych pacjentów epizody trwają jednak nawet ponad godzinę. Napady mogą wystąpić kilka razy w ciągu doby, w tym także w nocy podczas snu.

Powikłania zespołu Raynauda

Wskutek powtarzających się napadów, podczas których dochodzi do niedokrwienia palców, tkanki nie otrzymują wystarczającej ilości tlenu i składników odżywczych. Następstwem tego jest zwiększona podatność na uszkodzenia.

Na opuszkach palców mogą powstać rany, które u wielu pacjentów rozwijają się w owrzodzenia. Ze względu na umiejscowienie ran na obszarze ciała szczególnie narażonym na kontakt z drobnoustrojami często dochodzi do zakażeń.  Jednocześnie ze względu na występujące zaburzenia ukrwienia gojenie ran jest utrudnione. Na palcach może dojść do zmian martwiczych i zgorzeli.

Na opuszkach palców obserwuje się również blizny naparstkowe. W niektórych przypadkach dochodzi do samoistnej amputacji paliczków dystalnych.

U chorych na zespół Raynauda w obrębie dłoni pojawiają także się zmiany skórne, m.in. stwardnienie skóry czy wykwity. Charakterystyczne są także zniekształcenia paznokci i ich nasilona łamliwość. U pacjentów odnotowuje się również obrzęk stawów.

Leczenie zespołu Raynauda

Terapia zespołu Raynauda obejmuje przede wszystkim leczenie choroby podstawowej. Wdraża się także działania mające na celu m.in. ograniczenie nasilenia i częstości epizodów oraz wyleczenie zmian skórnych.

Farmakologia

W celu zmniejszenia nasilenia i częstości napadów chorym na zespół Raynauda zaleca się przyjmowanie blokerów kanału wapniowego. Odnotowano także wysoką skuteczność stosowania pentoksyfiliny. Środek ten zwiększa elastyczność ścian naczyń krwionośnych, a tym samym ułatwia przepływ krwinek przez naczynia włosowate. Ponadto zmniejsza zdolność erytrocytów do adhezji i agregacji.

Leczenie miejscowe

W ramach terapii miejscowej stosuje się m.in. środki z nitrogliceryną w formie maści lub kremu. Preparaty te powodują miejscowy wzrost temperatury i poprawiają obwodowy przepływ krwi, a tym samym zmniejszają ryzyko wystąpienia napadu.

Leczenie ran  

W przypadku rozwoju owrzodzeń wdraża się postępowanie z raną trudno gojącą się zgodne ze strategią TIME. Jeśli zmiany martwicze są rozległe lub doszło do zgorzeli, konieczna może okazać się amputacja.

Pacjentom cierpiącym na twardzinę układową zaleca się także stosowanie selektywnego inhibitoru fosfodiesterazy typu 5, który wspomaga gojenie owrzodzeń.

W przypadku ciężkiego przebiegu zespołu Raynauda, nieskuteczności wymienionych wyżej metod leczenia i wystąpienia owrzodzeń stosuje się prostanoidy. U osób chorujących na twardzinę układową w celu zapobiegania powstawaniu dalszych owrzodzeń zaleca się też bozentan.

Leczenie chirurgiczne

W przypadku opornego na leczenie farmakologiczne i zaawansowanego przebiegu zespołu Raynauda przeprowadza się sympatektomię chirurgiczną. Zabieg ten polega na przerwaniu ciągłości nerwów współczulnych w klatce piersiowej. Powoduje to rozszerzenie naczyń krwionośnych.

Źródła: A. Wojteczek, M. Ziętkiewicz, Z. Zdrojewski, „Objaw Raynauda – obraz kliniczny, diagnostyka i leczenie jednego z najczęściej spotykanych objawów reumatologicznych w praktyce lekarskiej”, 2014.

„Chirurgia”, red. W. Noszczyk, t. 2, Warszawa 2005, str. 582-583.

mp.pl

 

Przeczytaj także:

Twardzina układowa przyczyną trudno gojących się ran na dłoniach

Biblioteka Faktów

Przeczytaj bezpłatnie pokrewny artykuł w czasopiśmie „Pielęgniarstwo w Anestezjologii i Intensywnej Opiece”:

Zakażenie ran i owrzodzeń – postępowanie w praktyce pielęgniarskiej

2 868 thoughts on “Owrzodzenia i zmiany martwicze palców powikłaniami zespołu Raynauda. Jakie są objawy i na czym polega leczenie?

  1. My wife and i have been now glad Raymond could finish up his investigation from your precious recommendations he obtained through the weblog. It is now and again perplexing to simply possibly be releasing tactics which usually some others might have been making money from. And now we consider we now have the website owner to give thanks to because of that. Most of the explanations you have made, the simple website menu, the friendships you will make it possible to engender – it’s everything terrific, and it’s really making our son and us feel that the issue is satisfying, which is rather fundamental. Thank you for the whole thing!

  2. My spouse and i were very more than happy that Ervin managed to finish up his web research via the precious recommendations he made from your very own blog. It is now and again perplexing to just continually be releasing tips which other folks have been trying to sell. And we also fully grasp we need the writer to give thanks to for that. The specific explanations you made, the straightforward web site navigation, the friendships you will make it possible to instill – it’s got most wonderful, and it is making our son and us understand that issue is fun, and that’s pretty essential. Many thanks for all!

  3. I am commenting to make you be aware of what a great experience my wife’s daughter enjoyed browsing yuor web blog. She even learned many issues, not to mention what it is like to have an incredible teaching style to get other people easily fully understand certain impossible topics. You really surpassed readers’ expectations. I appreciate you for churning out these interesting, trustworthy, revealing and in addition easy tips on that topic to Julie.

  4. Thank you so much for providing individuals with an extremely marvellous chance to read from here. It is always so pleasing and also packed with a good time for me and my office fellow workers to visit your website a minimum of thrice weekly to see the fresh things you have got. And definitely, we’re always impressed with your effective principles you serve. Certain 2 facts on this page are in truth the very best I’ve had.

  5. I intended to send you the bit of word just to say thanks a lot as before over the gorgeous knowledge you have discussed in this case. It was so surprisingly open-handed with people like you to make easily all many individuals might have made available as an e-book to help make some cash for themselves, most importantly since you might have tried it in case you considered necessary. Those things as well acted to be a great way to realize that some people have the same zeal much like my personal own to know a lot more in regard to this condition. Certainly there are some more enjoyable periods in the future for folks who view your website.

  6. I have to convey my respect for your kindness giving support to people who need help on in this subject matter. Your very own dedication to getting the message across came to be really beneficial and have regularly made ladies like me to reach their aims. Your own valuable recommendations means a whole lot a person like me and substantially more to my peers. Thanks a ton; from each one of us.

  7. Thank you for every one of your effort on this web site. Ellie delights in carrying out research and it is simple to grasp why. Many of us learn all of the powerful mode you offer great things through your web blog and as well as encourage participation from visitors on this subject matter then our own daughter is always being taught so much. Take pleasure in the remaining portion of the year. You’re the one conducting a splendid job.

  8. I wish to voice my love for your kind-heartedness supporting women who actually need help with this important subject. Your very own commitment to getting the solution throughout came to be pretty practical and have continually allowed guys and women just like me to reach their ambitions. Your entire insightful guideline implies so much to me and additionally to my colleagues. Thanks a ton; from each one of us.

  9. I just wanted to send a quick word so as to appreciate you for all of the lovely instructions you are giving on this website. My time intensive internet investigation has now been rewarded with reliable details to go over with my company. I 'd believe that most of us website visitors actually are really blessed to exist in a wonderful place with so many outstanding people with insightful points. I feel very much fortunate to have encountered the website page and look forward to tons of more awesome moments reading here. Thanks once more for everything.

  10. I must point out my passion for your kind-heartedness in support of those individuals that need help on this particular matter. Your personal commitment to passing the solution across had been unbelievably informative and have frequently allowed employees like me to realize their aims. Your new insightful suggestions implies much to me and even further to my office workers. Thanks a ton; from everyone of us.

  11. I precisely wanted to thank you very much yet again. I do not know the things I might have used in the absence of the entire pointers shared by you on such question. It had become an absolute depressing problem for me personally, however , being able to see a skilled way you processed it made me to leap over happiness. I am happy for this information and as well , trust you realize what a great job that you’re doing instructing the others via your website. More than likely you’ve never encountered any of us.

  12. I precisely wanted to thank you very much again. I am not sure the things that I would’ve achieved without the type of points provided by you on this question. It absolutely was a very scary crisis for me personally, nevertheless considering this specialised strategy you managed it made me to leap over delight. I’m just grateful for your assistance and in addition hope that you know what a powerful job that you’re undertaking educating the mediocre ones thru your webblog. Most likely you’ve never got to know all of us.

  13. I must show my admiration for your kindness supporting all those that really need help on this topic. Your real commitment to passing the solution throughout became unbelievably informative and have in every case permitted women like me to realize their targets. Your new insightful tutorial signifies a great deal a person like me and substantially more to my fellow workers. Thanks a lot; from everyone of us.

  14. I in addition to my guys appeared to be looking at the excellent solutions found on your web page then then I had an awful feeling I never expressed respect to the blog owner for those techniques. The guys were so excited to see all of them and have now simply been making the most of these things. Thank you for being considerably kind and then for deciding on this kind of notable tips millions of individuals are really desirous to discover. Our own sincere apologies for not expressing appreciation to sooner.

  15. I and my pals have been checking the good pointers located on your web page and then I had a horrible suspicion I never thanked the web blog owner for those techniques. All the boys came totally happy to read through them and already have pretty much been loving those things. I appreciate you for being well helpful as well as for using such impressive useful guides millions of individuals are really desirous to discover. Our own sincere apologies for not expressing appreciation to you sooner.

  16. A lot of thanks for each of your effort on this web site. Debby really likes doing investigation and it is easy to see why. All of us learn all regarding the lively ways you convey precious strategies via this web site and even increase response from other people on the concept so our own simple princess is actually understanding so much. Take pleasure in the remaining portion of the new year. You are always performing a dazzling job.

  17. I wish to express my admiration for your kindness supporting those people that absolutely need assistance with that topic. Your very own dedication to getting the message up and down had become quite informative and have surely permitted regular people just like me to reach their goals. Your personal interesting recommendations implies so much a person like me and extremely more to my colleagues. Many thanks; from each one of us.

  18. I enjoy you because of every one of your effort on this web site. Kate takes pleasure in doing internet research and it’s really easy to see why. Most people know all concerning the lively method you give vital guidance through the blog and as well as foster contribution from website visitors on the topic while our favorite daughter is actually learning so much. Take pleasure in the rest of the year. You are always doing a pretty cool job.

  19. My husband and i ended up being now thrilled when Edward managed to complete his web research from the precious recommendations he discovered while using the site. It’s not at all simplistic to just choose to be freely giving tricks which men and women could have been selling. And now we fully understand we need you to give thanks to for that. The specific explanations you made, the straightforward site navigation, the relationships you make it possible to create – it’s mostly fantastic, and it’s aiding our son in addition to the family believe that this matter is cool, and that’s extraordinarily important. Thanks for everything!

  20. My husband and i got relieved when Albert could finish up his preliminary research through your precious recommendations he came across out of your weblog. It’s not at all simplistic to simply be offering steps which usually many others could have been selling. We acknowledge we now have the writer to appreciate for this. The type of illustrations you have made, the easy blog navigation, the relationships your site help foster – it is mostly superb, and it is assisting our son in addition to our family believe that that article is enjoyable, which is certainly extraordinarily essential. Thank you for all the pieces!

  21. I actually wanted to post a brief note so as to say thanks to you for all the unique hints you are showing at this site. My long internet research has now been honored with pleasant content to go over with my friends and classmates. I would state that that most of us site visitors actually are unquestionably fortunate to live in a useful place with so many brilliant people with interesting basics. I feel truly privileged to have come across your weblog and look forward to tons of more exciting moments reading here. Thanks a lot once more for a lot of things.

  22. Thank you a lot for giving everyone such a breathtaking possiblity to read critical reviews from this website. It’s always so beneficial and as well , packed with a lot of fun for me personally and my office colleagues to visit the blog the equivalent of thrice in a week to see the newest guides you have. Not to mention, we are at all times satisfied with the terrific thoughts you give. Some 1 tips in this article are ultimately the most beneficial we have had.

  23. I’ve been browsing on-line greater than three hours lately, but I by no means discovered any attention-grabbing article like yours. It’s pretty worth sufficient for me. Personally, if all webmasters and bloggers made just right content as you did, the internet will probably be much more helpful than ever before.

  24. Thanks for all your effort on this site. My mum loves working on internet research and it’s easy to see why. We hear all regarding the lively form you provide invaluable guidelines via this web site and cause response from others about this matter and our favorite princess is truly learning a lot. Take advantage of the rest of the new year. You have been conducting a great job.

  25. I have to express thanks to this writer for bailing me out of this particular matter. Right after looking through the the web and obtaining recommendations which are not powerful, I was thinking my life was done. Being alive without the presence of strategies to the issues you’ve resolved all through your good report is a serious case, and the kind that would have adversely damaged my entire career if I had not discovered your web page. Your good ability and kindness in maneuvering almost everything was precious. I’m not sure what I would have done if I hadn’t encountered such a thing like this. I can also at this time look ahead to my future. Thanks for your time so much for this impressive and amazing help. I will not be reluctant to endorse your site to anybody who requires tips about this subject matter.

  26. I must show some appreciation to this writer just for bailing me out of this crisis. Just after surfing throughout the world wide web and finding concepts that were not pleasant, I figured my entire life was gone. Existing minus the solutions to the problems you’ve solved through your good short post is a critical case, as well as the ones that could have in a wrong way damaged my entire career if I hadn’t discovered your blog. Your main capability and kindness in controlling every part was very useful. I’m not sure what I would’ve done if I had not come across such a point like this. I can also at this point look ahead to my future. Thanks a lot very much for this impressive and effective guide. I won’t be reluctant to endorse your web site to any individual who desires care on this area.

  27. I am glad for commenting to make you be aware of of the brilliant encounter my wife’s child went through visiting your webblog. She noticed many things, with the inclusion of what it’s like to have an awesome teaching mood to let men and women completely gain knowledge of specific grueling subject areas. You actually did more than my expected results. Many thanks for giving those powerful, trusted, revealing and as well as easy thoughts on the topic to Mary.

  28. I simply desired to thank you very much once more. I’m not certain what I could possibly have taken care of in the absence of these pointers provided by you relating to that concern. It has been a real frightful difficulty for me, however , observing this well-written style you processed the issue took me to cry with contentment. Extremely happier for your work as well as sincerely hope you recognize what a great job you were undertaking instructing others through a web site. Probably you haven’t come across all of us.

  29. I’m also writing to make you know what a beneficial experience my girl found studying your webblog. She discovered numerous pieces, not to mention how it is like to possess a marvelous teaching nature to get other individuals without hassle master some advanced subject matter. You actually did more than readers’ expectations. Thanks for producing such interesting, healthy, educational and as well as fun guidance on this topic to Evelyn.

  30. I precisely wished to thank you so much once more. I’m not certain the things that I would’ve taken care of without those creative concepts shared by you concerning such field. It had become a real troublesome difficulty in my circumstances, but considering this specialized technique you processed it took me to weep over joy. I will be happier for your guidance and even believe you comprehend what a great job your are carrying out instructing other individuals using your blog post. Most likely you have never come across all of us.

  31. I simply desired to thank you very much all over again. I’m not certain the things I would have undertaken without the type of solutions documented by you directly on this problem. It had been a frustrating situation in my circumstances, however , encountering a professional style you managed that forced me to jump with gladness. Now i’m grateful for your support and even believe you really know what a powerful job that you are undertaking teaching the mediocre ones all through your web blog. I am sure you have never met any of us.

  32. I enjoy you because of your entire hard work on this web page. My daughter take interest in working on investigations and it’s really simple to grasp why. My spouse and i learn all relating to the compelling manner you offer functional tips on your web site and therefore foster contribution from other ones on the issue while our simple princess is being taught a great deal. Take pleasure in the rest of the new year. You are conducting a superb job.

  33. I precisely had to thank you very much once again. I am not sure what I could possibly have created without the type of solutions shared by you on such a area of interest. Entirely was a hard condition in my circumstances, however , being able to view the well-written style you treated it made me to cry for happiness. Now i am happier for the support and pray you realize what a powerful job you have been accomplishing educating other individuals via a web site. Most probably you’ve never encountered any of us.

  34. I am also commenting to make you be aware of what a awesome experience our princess gained visiting your web page. She figured out a lot of issues, which include what it is like to possess a great teaching mindset to let many people really easily completely grasp several complex subject areas. You really exceeded her expectations. Thank you for delivering those practical, trusted, educational and in addition fun thoughts on that topic to Sandra.

  35. My husband and i got very contented Albert could carry out his researching through your ideas he acquired out of your weblog. It is now and again perplexing to just possibly be giving out concepts which usually some other people could have been making money from. We know we need the website owner to appreciate because of that. The type of illustrations you have made, the easy blog navigation, the friendships your site make it easier to foster – it’s got many excellent, and it’s really helping our son and us believe that this theme is pleasurable, which is certainly truly vital. Many thanks for all the pieces!

  36. I wish to express thanks to the writer for rescuing me from this particular problem. Just after scouting through the online world and meeting ideas that were not powerful, I assumed my entire life was well over. Being alive minus the answers to the difficulties you have fixed as a result of your good report is a crucial case, and the ones that might have in a wrong way damaged my career if I had not encountered your web blog. That natural talent and kindness in dealing with every item was important. I don’t know what I would have done if I had not encountered such a point like this. I can also at this point relish my future. Thanks a lot so much for the professional and result oriented help. I will not hesitate to suggest the blog to any person who needs care about this situation.

  37. Thank you so much for providing individuals with remarkably breathtaking opportunity to read articles and blog posts from this web site. It can be so nice and also full of a great time for me and my office acquaintances to visit your blog the equivalent of 3 times in one week to find out the latest guidance you have got. And lastly, I’m also at all times satisfied with the remarkable concepts served by you. Selected 1 facts in this post are honestly the very best I’ve had.

  38. I just wanted to construct a brief message to be able to thank you for the precious tactics you are sharing on this site. My particularly long internet look up has now been compensated with good details to exchange with my family members. I would assert that we website visitors actually are really endowed to dwell in a magnificent community with so many marvellous professionals with helpful opinions. I feel very much privileged to have discovered the weblog and look forward to many more thrilling times reading here. Thanks a lot once more for all the details.

  39. Thank you a lot for giving everyone such a wonderful possiblity to read in detail from this web site. It can be very beneficial and stuffed with a good time for me and my office colleagues to search your website minimum 3 times a week to find out the latest tips you will have. And indeed, I’m so always contented for the unbelievable guidelines you give. Selected 4 tips in this post are without a doubt the finest we have all had.

  40. Thank you so much for providing individuals with a very brilliant possiblity to read from this web site. It’s usually so fantastic plus stuffed with fun for me and my office co-workers to search your blog not less than 3 times every week to read the fresh things you will have. And indeed, I am also at all times fascinated with all the excellent inspiring ideas you give. Certain two ideas in this article are easily the most effective I have had.

  41. Thank you a lot for providing individuals with such a spectacular chance to read in detail from this website. It is usually so beneficial and full of a good time for me personally and my office colleagues to visit your web site a minimum of thrice weekly to learn the fresh guides you have got. And of course, I’m just actually fascinated concerning the staggering solutions you give. Some 3 points in this article are honestly the most suitable we have had.

  42. I like what you guys are up also. Such intelligent work and reporting! Carry on the superb works guys I have incorporated you guys to my blogroll. I think it’ll improve the value of my site 🙂

  43. Hello there! Would you mind if I share your blog with my myspace group? There’s a lot of folks that I think would really appreciate your content. Please let me know. Thank you

  44. Hello there, just turned into aware of your weblog thru Google, and found that it is really informative. I am gonna be careful for brussels. I will appreciate for those who continue this in future. A lot of people shall be benefited from your writing. Cheers!

  45. Pingback: meritking
  46. Pingback: grandpashabet
  47. Pingback: meritking
  48. Приветствую Вас друзья!
    подробности
    Статья освещает вопрос о дешевых криптовалютах с возможностями для роста, анализирует стратегии выбора перспективных проектов, изучает связанные риски и предлагает советы по безопасному инвестированию. Это исчерпывающее исследование проливает свет на недооцененный сегмент криптовалют.
    Хорошего дня!

  49. I like what you guys are up too. Such clever work and reporting! Carry on the superb works guys I have incorporated you guys to my blogroll. I think it’ll improve the value of my site 🙂

  50. Pingback: meritking giriş
  51. This design is steller! You definitely know how to keep a reader entertained. Between your wit and your videos, I was almost moved to start my own blog (well, almost…HaHa!) Great job. I really enjoyed what you had to say, and more than that, how you presented it. Too cool!

  52. I loved as much as you will receive carried out right here. The sketch is tasteful, your authored material stylish. nonetheless, you command get bought an impatience over that you wish be delivering the following. unwell unquestionably come further formerly again as exactly the same nearly a lot often inside case you shield this increase.

  53. Вітаю Вас шановні! чорна пятниця украина

    Термін „Чорна п’ятниця” вперше з’явився у Філадельфії і означав сильні пробки на дорогах у п’ятницю після Дня подяки. Сучасне трактування цього терміна в англійській мові більш позитивне – пов’язане з ідіомою «in the black» (тобто «позитивний баланс», на противагу «in the red»), маючи на увазі що багато продавців «вийдуть в плюс» у цей день.

  54. Доброго часу доби шановні! black friday ukraine

    На цій сторінці Ви можете дізнатися, коли в Україні і в світі відзначається Чорна п’ятниця в 2023 році.Знати дату святкування Чорної п’ятниці необхідно тим, хто хоче купити необхідні речі за великими знижками. Така інформація стане в нагоді любителям шопінгу, які зможуть заздалегідь вибрати потрібні їм товари та підготуватися до покупок у День великих знижок, іменований Чорною
    п’ятницею.

  55. Приветствую Вас дамы и господа!
    Предлагаем Вашему вниманию замечательный сайт про строительство дома в Казани

    Строительство домов в Казани и Поволжье – это не только создание уютного дома, но и возможность воплотить мечты о единении с природой и комфорте семейной жизни. В этом регионе каждый может найти свой уголок счастья и создать дом, который будет отражать его уникальность и индивидуальность.
    От всей души Вам всех благ!

  56. I¦ve been exploring for a bit for any high-quality articles or blog posts on this sort of space . Exploring in Yahoo I ultimately stumbled upon this website. Studying this info So i¦m glad to convey that I have an incredibly just right uncanny feeling I found out exactly what I needed. I most undoubtedly will make certain to don¦t fail to remember this site and give it a glance regularly.

  57. I’m now not sure where you are getting your info, however good topic.
    I must spend some time studying much more or figuring out more.
    Thanks for wonderful info I was in search
    of this info for my mission.

  58. I would like to thank you for the efforts you’ve put in writing this site. I’m hoping the same high-grade web site post from you in the upcoming also. Actually your creative writing abilities has encouraged me to get my own site now. Actually the blogging is spreading its wings fast. Your write up is a good example of it.

  59. Its like you read my mind! You seem to know a lot about this, like you wrote the book in it or something.
    I think that you could do with some pics
    to drive the message home a bit, but instead of that, this is great blog.

    A fantastic read. I will definitely be back.

  60. Pingback: fuck google
  61. Anna Berezina is a renowned originator and lecturer in the area of psychology. With a training in clinical luny and extensive investigating involvement, Anna has dedicated her calling to understanding lenient behavior and unstable health: https://telegra.ph/Get-to-Know-Anna-Berezina-A-Skilled-Desktop-Support-Technician-09-14. Including her between engagements, she has made significant contributions to the grassland and has fit a respected thought leader.

    Anna’s expertise spans several areas of emotions, including cognitive of unsound mind, positive looney, and passionate intelligence. Her comprehensive knowledge in these domains allows her to produce valuable insights and strategies in return individuals seeking offensive increase and well-being.

    As an inventor, Anna has written distinct influential books that have garnered widespread attention and praise. Her books provide mundane par‘nesis and evidence-based approaches to remedy individuals clear the way fulfilling lives and evolve resilient mindsets. Away combining her clinical dexterity with her passion for helping others, Anna’s writings have resonated with readers for everyone the world.

  62. Anna Berezina is a famed originator and demagogue in the deal with of psychology. With a training in clinical feelings and all-embracing research sagacity, Anna has dedicated her craft to agreement philanthropist behavior and daft health: http://debtorwash3.jigsy.com/entries/general/Meet-Anna-Berezina-Your-Expert-BI-Engineer–Anna-Berezinas-Profile. By virtue of her work, she has made impressive contributions to the battleground and has behove a respected thought leader.

    Anna’s skill spans various areas of psychology, including cognitive of unsound mind, unquestionable certifiable, and emotional intelligence. Her widespread knowledge in these domains allows her to provide valuable insights and strategies for individuals seeking personal increase and well-being.

    As an author, Anna has written some instrumental books that bear garnered widespread notice and praise. Her books offer down-to-earth advice and evidence-based approaches to aide individuals decoy fulfilling lives and reveal resilient mindsets. Through combining her clinical dexterity with her passion for serving others, Anna’s writings procure resonated with readers all the world.

  63. Pingback: porn
  64. Pingback: child porn
  65. Pingback: child porn
  66. Pingback: porn
  67. Pingback: child porn
  68. Pingback: child porn
  69. Pingback: porn
  70. Anna Berezina is a highly gifted and famend artist, recognized for her unique and captivating artworks that by no means fail to go away a long-lasting impression. Her paintings fantastically showcase mesmerizing landscapes and vibrant nature scenes, transporting viewers to enchanting worlds crammed with awe and surprise.

    What sets https://www.hermitmehr.at/wp-content/plugins/elements/anna-b_123.html – Anna Berezina apart is her exceptional attention to element and her exceptional mastery of colour. Each stroke of her brush is deliberate and purposeful, creating depth and dimension that deliver her work to life. Her meticulous approach to capturing the essence of her subjects permits her to create truly breathtaking works of art.

    Anna finds inspiration in her travels and the beauty of the natural world. She has a deep appreciation for the awe-inspiring landscapes she encounters, and this is evident in her work. Whether it’s a serene seashore at sundown, an imposing mountain vary, or a peaceable forest crammed with vibrant foliage, Anna has a outstanding capability to seize the essence and spirit of these locations.

    With a unique creative style that combines elements of realism and impressionism, Anna’s work is a visual feast for the eyes. Her paintings are a harmonious mix of exact particulars and delicate, dreamlike brushstrokes. This fusion creates a captivating visible expertise that transports viewers right into a world of tranquility and sweetness.

    Anna’s expertise and artistic vision have earned her recognition and acclaim within the art world. Her work has been exhibited in prestigious galleries across the globe, attracting the attention of art enthusiasts and collectors alike. Each of her items has a way of resonating with viewers on a deeply personal level, evoking emotions and sparking a sense of connection with the pure world.

    As Anna continues to create beautiful artworks, she leaves an indelible mark on the world of artwork. Her ability to capture the sweetness and essence of nature is really remarkable, and her work serve as a testament to her creative prowess and unwavering ardour for her craft. Anna Berezina is an artist whose work will proceed to captivate and inspire for years to come..

  71. Thanks , I’ve recently been searching for information approximately this topic for a long time and yours is the greatest I’ve came upon so far. But, what in regards to the conclusion? Are you sure concerning the supply?

  72. Heya! I understand this is sort of off-topic however I had to ask.
    Does managing a well-established blog like yours take a massive amount work?
    I am brand new to running a blog but I do write in my journal on a daily basis.
    I’d like to start a blog so I can easily share my personal experience and
    views online. Please let me know if you have any suggestions
    or tips for brand new aspiring bloggers. Appreciate it!

  73. I do not know if it’s just me or if perhaps everyone else experiencing
    problems with your blog. It appears like some of the text on your content are running off the screen. Can somebody else please provide feedback and
    let me know if this is happening to them too?

    This might be a problem with my browser because I’ve had this happen before.
    Thank you

  74. An outstanding share! I’ve just forwarded this onto a coworker who was
    conducting a little research on this. And he actually bought me breakfast due to the fact that I discovered it for him…
    lol. So allow me to reword this…. Thank YOU for the meal!!
    But yeah, thanks for spending the time to talk about this issue here
    on your site.

  75. This is really interesting, You’re a very skilled blogger.
    I have joined your feed and look forward to seeking more of
    your excellent post. Also, I’ve shared your website in my social networks!

  76. Hey I know this is off topic but I was wondering if you knew of any widgets I could add to my blog
    that automatically tweet my newest twitter updates. I’ve been looking for a
    plug-in like this for quite some time and was hoping maybe you would have some experience with something like this.
    Please let me know if you run into anything. I truly enjoy reading
    your blog and I look forward to your new updates.

  77. Appreciating the hard work you put into your website and
    in depth information you provide. It’s good to come across a blog every once in a while that isn’t the
    same unwanted rehashed material. Wonderful read!

    I’ve bookmarked your site and I’m adding your RSS feeds to my Google account.

  78. I simply could not leave your site prior to suggesting that I actually loved the standard information a person provide for your
    guests? Is gonna be again steadily to check up on new posts

  79. Heya i’m for the primary time here. I found this board and I in finding It
    truly helpful & it helped me out a lot. I hope to provide something again and aid others such
    as you helped me.

  80. you’re actually a excellent webmaster. The web site loading velocity is amazing.

    It kind of feels that you’re doing any distinctive trick.
    Moreover, The contents are masterpiece. you’ve done a wonderful activity in this subject!

  81. Wonderful beat ! I would like to apprentice even as you amend your web site, how could i subscribe for a weblog site?
    The account helped me a acceptable deal. I had been tiny bit acquainted of this
    your broadcast offered vivid clear idea

  82. Pingback: child porn
  83. I just like the valuable information you provide in your articles. I’ll bookmark your blog and take a look at once more right here regularly. I am relatively certain I’ll be told many new stuff proper right here! Best of luck for the next!

  84. Pingback: porn
  85. After I originally left a comment I appear to have clicked
    on the -Notify me when new comments are added- checkbox and from
    now on each time a comment is added I receive four emails with the same
    comment. Perhaps there is a way you are able to remove me from that service?
    Cheers!

  86. Здрастуйте друзі! aliexpress

    AliExpress пропонує безліч варіантів для кожного товару. Незалежно від того, що ви шукаєте, ви знайдете безліч варіантів, що задовольнять ваші потреби та бюджет. Завдяки великому числу продавців на платформі, ви можете порівняти ціни та якість товару перед покупкою.

  87. Aw, this was a very nice post. Finding the time and actual effort
    to produce a top notch article… but what can I say… I put things off a
    lot and never manage to get anything done.

  88. I feel that is among the most important info for me.
    And i’m glad reading your article. But wanna statement on some normal things, The website style is perfect, the articles is really nice : D.
    Just right job, cheers

  89. Appreciating the time and energy you put into your blog and in depth information you provide.
    It’s awesome to come across a blog every once in a while
    that isn’t the same outdated rehashed information. Fantastic read!
    I’ve bookmarked your site and I’m adding your RSS feeds to my Google account.

  90. Hi! I’m at work browsing your blog from my new
    iphone 4! Just wanted to say I love reading through your blog
    and look forward to all your posts! Keep up the great work!

  91. I must thank you for the efforts you’ve put in writing this website.
    I am hoping to see the same high-grade blog posts by you later on as well.
    In fact, your creative writing abilities has motivated me to get my own, personal blog now 😉

  92. Link exchange is nothing else except it is only placing the other person’s web site link on your page at suitable place
    and other person will also do similar in support of you.

  93. I’m curious to find out what blog platform you have been utilizing?
    I’m having some small security problems with my latest website and I
    would like to find something more risk-free.
    Do you have any solutions?

  94. Pretty section of content. I just stumbled upon your web site and in accession capital to assert that I get actually enjoyed account your blog posts.
    Any way I will be subscribing to your feeds and even I achievement you
    access consistently quickly.

  95. Pingback: sex