Nurse Jackie - Season 7 Episode 8. Jackie's addiction becomes unmanageable, while Kevin behaves evasively, O'Hara becomes ER chief, Coop's mothers divorce, and Eddie, who is back at the hospital, begins dating Jackie's newly single sister- in- law. Merritt Wever - IMDb. Merritt Wever grew up in downtown New York and has been acting since she was very young. She graduated from La. Guardia High School and then attended Sarah Lawrence College. Merritt Wever bids 'Nurse Jackie' a fond goodbye. Merritt Wever plays nurse Zoey on Showtime's 'Nurse Jackie.'. A little weight gain never hurt. She was raised by her mother to be politically progressive. When not acting or protesting, Merritt enjoys spending time with her cat Spooky or going to the theater with a friend.. I have not had to go to the extent that Jackie has onscreen, but Zoey and Lenny definitely display their.
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How much should the average adult. The guidelines suggest that you spread out this exercise during the course of a week.I am looking for a definitive answer once and for all on how much he should eat a day. I have heard answers ranging from 1 cup to 3 cups of dog food every day. He is mostly an indoor dog, but he spends time outdoors running around with our kids and our other dog, a setter- retriever mix. He also gets an ENORMOUS amount of exercise inside the house, playing fetch, wrestling, and tirelessly chasing our cat! Your intensity should be. If he's still gaining weight. I used to feed him 1 and a half cups twice a day, and he developed a weight problem. The owner of a small, inactive dog was appalled at that amount, and she advised that I should feed him one half cup twice a day. I've been doing that for a week, and the poor little guy seems hungry all the time! I think he needs more calories than her dog because he is more active. I feed him Alpo dog food, sometimes Purina (always dry food). Home Health Growth & Development Average Weight Gain for Breastfed Babies. How much weight should I expect my. The Diet for a Welsh Corgi. If your corgi has not eaten much of these 'people foods. I don't buy cheap no name brands, but I can't afford the high priced stuff like Iams, either. I've been working on making sure everyone in the family obeys the no- table- food or snacks rule, and we've been keeping him active, but I'm very concerned about making sure that I don't feed him way too much or way too little. Also, another friend advised that I replace part of his food with green beans (which he loves). But a half cup seems like such a tiny amount, and I'm afraid that if I take part of that away in favor of green beans, he will be malnourished. Thanks, Kristen, I really appreciate that you're taking time to help me with my problem! Ericka Myre Answer. Ericka, good question, but there honestly IS no definitive answer to the question . Because he isn't eating a high quality dog food, he will need to be fed more of it to get the nutrition his body needs. Foods like Purina, Iams, Pedigree, Science Diet, and all the other foods than can be bought at the grocery store or places like Kmart and Walmart are about the same (even though the prices make you *think* one is better than the other), and are full of cheap, undigestible fillers that provide very little nutrition. I'm not trying to make you feel bad, since you say that Purina and Alpo is all you can afford. If that's what you have to feed, then that's what you have to feed. According to the feeding recommendations on the back of a bag of Purina Dog Chow, it says to feed your dog (whose weight should be between 2. If you're going to feed him twice a day, split it in half and give him 3/4 cup at each feeding, so it totals to 1. Personally, I'd feed him just 1 cup per day. If he loses weight on that, then wait until he gets down to 2. If he starts gaining weight again, then cut back to 1 1/4 cups per day for a week or two. If he's still gaining weight, then cut back down to 1 cup and stick to that. Subsituting part of his meal with green beans will not hurt him in the least. Now, if you were feeding nothing BUT green beans, that would be a problem, but feeding him 1 cup of dog food and 1/2 cup of green beans is perfectly fine, and will help to keep him from feeling hungry all the time. Just don't salt or season them. Good luck and please let me know if there's anything else I can help you with! Spicy Chapati Rolls ( Weight Loss After Pregnancy ) recipe . Or Sign In here, if you are an existing member. If the respective id is not registered, a new Tarladalal. If you want calorie for weight loss chart, then click here. Chapathi Side Dish Healthy Foods. Side Dish for Chapati - Duration: 4:52. Side dish for chapatis or rice Stuffed okra recipe- How to make bharwan bhindi- Side dish for chapatis. Tomato Kurma Recipe-Thakkali Kurma-Side dish for Chapati. Looks like a very delicious side dish. Vermicelli recipes/Semiya recipes (7) Weight loss recipes. Recipes for low calorie side dish for chapathi. How To Make Soft Chapati/Chapathi. Today I did not have mood to make any side dish for that. After making the chilli chapati. Bobby on 28 Day Weight Loss and Detox. Capsicum Kurma (Korma) / Bell Pepper Kurma / Pepper Gravy - Sidedish for Chapati. Everyone at home relished this dish. Kelly Osbourne Loses 7. Pounds By Hula Hooping. ABC News' Rachel Smith reports: Hoopnotica is the latest Hollywood weight- loss craze causing quite the hoopla among celebs. On Saturday nights my friends and I put on ridiculous outfits and hula- hoop and dance when everyone else is at 'da club.' We call it #Hip. Hop. Anonymous. Adam Lambert is in it. We live in the same building, and random people show up. The next morning you're like, 'Oh, my God, I'm so sore,' but you had the best night ever. After originally weighing 1. Michelle Obama, Catherine Zeta Jones, Jason Mraz and Beyonce also reportedly enjoy the exercise. Weight Loss How Many Calories Per Day How To Reduce Belly Fat By Running How To Weight Loss Hula Hoop Meal Plan To Lose 30 Pounds In One Month. Top 10 Hula Hoop Exercises. Hula Hoop workout has. Hula Hoop Workout Weight Loss. How Many Calories Can I Burn Hula Hooping? Hey Hooping. org –I’ve been thinking lately about the various claims out there about how many calories hooping burns – one sees anywhere between 3. How Much Should I Eat Per Day To Lose Weight. How Many Calories Can I Burn Hula Hooping? I think she said the participants averaged burning 600 calories per hour. Any chance your detective skills and readers can get to the bottom of this for us all? Love, Lara. Dear Lara,How many calories an individual burns hula hooping will always be relative, but the scientific claim we stand behind is 1. Some using simple math have thus concluded 6. This may be true in theory, and you can burn 6. The initial energy burning spike begins to decrease after ten minutes. Whether you’re sweating in an intensive hoop aerobics class or dreamily hoop dancing to Imogen Heap on a sunny day also plays a factor, as does your body weight and the weight of your hoop. That’s why giving a range – 3. Fitness Blender provides free full length workout videos. How many calories does a weighted hula hoop burn? Hula hoop your way to a thinner waist Did the hula hoop slim. How To Weight Loss Hula Hoop. If Jon really wants to lose 1 pound per week, he can consume 2,750 calories a day, while burning another 250 calories in a fitness. Weight Loss How To Use A Hula Hoop To. Lose Weight On 1200 Calories Per Day Weight Loss. Weight In A Week Amelia Freer Weight Loss. How to lose weight with help hula-hoop? Cara Dapatkan kurus dalam seminggu . Ini bukan pelan diet yoyo ya. Kehamilan Dan Bersalin Dengan Bertenaga. Hari kedua yang harus kau lakukan bila ingin turun 7 kilo dalam seminggu adalah mengikuti diet. Diet Alami Wajib Coba untuk. Lansing dalam masa 7 hari. Jom cuba menu ni. Cepatnya masa berlalu. Bagaimana dengan azam anda untuk menurunkan berat badan pada tahun 2. Adakah anda sudah mencapai matlamat atau masih lagi berusaha untuk mengejar target dan mendapatkan berat badan yang sesuai. Cuba ikuti cara pemakanan di bawah nanti, saya yakin anda pasti akan dapat menurunkan berat badan dalam masa 7 hari sekurang- kurangnya 7kg ke atas. Hari pertama. Hari pertama sangat penting, jangan cuba mengelat ye. Anda hanya perlu makan buah buahan yang ringan dan berair seperti epal, buah pear, tembikai dan sebagainya. Sepanjang hari anda boleh memakan apa sahaja buah yang mengandungi banyak air kecuali pisang. Pastikan juga anda meminum banyak air untuk mengelakkan hidrasi. Pastikan juga anda mengambil multivitamin untuk tenaga sepanjang hari. Hari kedua. Perkara yang harus anda lakukan untuk. Isikan hari anda dengan mengambil semua jenis sayuran. Anda boleh mengolah sayuran tersebut dengan makan secara mentah, salad, kukus atau rebus. Elakkan menggoreng atau menumis. Hari kedua juga anda perlu meminum banyak air untuk elakkan hidrasi. Hari ketiga. Menu hari ini ialah menu yang penuh warna warni. Campurkan buah- buahan dan sayuran untuk dijadikan jus. Anda boleh makan jus ini sehingga 3 kali sehari tetapi elakkan menggunakan buah pisang atau ubi kentang. Jangan lupa minum air secukupnya. Hari keempat. Hari ini anda boleh mengambil buah pisang atau susu. Boleh cuba buat milkshake pisang atau di makan secara terus. Jika anda berasa letih amalkan suplemen sepanjang 7 hari ini. Hari kelima. Badan anda akan terasa ringan pada hari kelima ini. Jadi hari ini anda boleh makan sebanyak 5 senduk sederhana nasi. Tambahkan 7- 8 potongan tomato. Anda boleh makan nasi sebanyak 2 kali sehari tetapi jangan sesekali makan nasi di waktu malam. Tingkatkan juga pengambilan air putih. Hari keenam. Ambil sarapan yang tinggi protein. Tengahari anda boleh makan nasi dengan sayuran dan ambil juga segelas susu di waktu malam. Hari ketujuh. Anda boleh mengambil 5 senduk nasi dengan sayuran serta buah- buahan yang sihat. Minumlah jus buah- buahan buatan sendiri untuk detox toksin daripada badan. Anda akan hilang berat sebanyak 7kg jika anda betul- betul mengikut diet di atas. Untuk membantu anda menurunkan berat dengan cepat sila ikuti tips dibawah: Kurangkan makan daging ayam atau lembu, gantikan ikan atau sumber protein lain seperti tauhu atau tempe.
Paling mudah minum ESP je. Pastikan anda mendapat tidur yang cukup dan berkualiti. Tidur yang cukup akan membuatkan selera anda stabil dan tidak akan makan dengan berlebihan. Jika anda kurang suka pada sayuran, anda boleh makan buah dengan aneka jenis dan warna. Ia membantu system penghadaman dan dalam masa yang sama juga boleh menyingkirkan toksin daripada tubuh. Masak sendiri menu anda. Kelebihan masak sendiri ialah anda lebih menikmatinya dan bebas memilih bahan- bahan yang diinginkan. Elakkan pewarna atau perisa tambahan dan cuba kurangkan kandungan gula. Anda boleh melakukan senaman mudah dan berperingkat. Contohnya, 2 hari pertama senaman ringan, 2 hari seterusnya jogging, 2 hari di gymnasium dan hari minggu memadai dengan mendaki tangga yang banyak. Jangan makan sebarangan, sebaliknya makan dengan jumlah yang betul dan waktu yang sesuai. Makan dalam kuantiti yang sedikit tapi kerap. Kesehatan: Diet OCD: Seminggu Turun 4 Kg, Tetap Bisa Makan Enak. Deddy Corbuzier, sebelum dan setelah OCD . Harus makan yang itu- itu lagi, tidak ada rasanya, ingin makan nasi Padang atau nasi uduk tidak boleh. Awalnya sih oke, berat turun, tapi lama- lama bosan dan kembali ke pola makan enak, akhirnya berat badan naik lagi. Seandainya ada diet yang tetap bisa makan enak, tidak perlu minum obat/suplemen atau makanan diet, olahraganya bisa di rumah, aman untuk wanita, badan lebih sehat, dan kalau bisa sih gratis tanpa keluar biaya sama sekali. Rasanya mustahil, ini adalah impian banyak orang. ADA! Perkenalkan, diet OCD! Diet OCD: Seminggu Turun 4 kg, Tetap. Sistem puasa dalam OCD. Untuk kurus harus disiplin dalam menjaga diet setiap hari. Menjaga senaman dan konsisten minima 2-3 kali seminggu. Masa kehamilan dibantu dengan. Ini jadi punca banyak diet kurus GAGAL! Untuk info kalori sepinggan. Follow tip dia yang telah berjaya turun 13 kg dalam masa 3. Fasa kehamilan sangatlah. Anda tidak salah baca, ada pola diet yang membuat Anda bisa makan enak, berat badan turun dan badan semakin sehat tanpa obat- obatan sama sekali. Nama diet ini adalah OCD, Obsessive Corbuzier's Diet. OCD sedang hangat dibicarakan dan sukses menurunkan berat badan banyak orang. Seperti namanya, OCD adalah diet yang dilakukan oleh Deddy Corbuzier dan disebarluaskan dalam bentuk ebook secara gratis. Dalam ebook yang ditulis oleh Deddy, OCD adalah pola diet yang sudah sangat lama diterapkan di China dan terlupakan. Padahal, diet ini sangat efektif menurunkan berat badan dan membuat tubuh pelakunya lebih sehat. Sistem puasa dalam OCDDiet OCD menerapkan sistem puasa dan jendela makan (waktu di mana Anda boleh makan). Jendela makan 8 jam, Anda makan dari jam 1. Anda boleh makan apa saja di jam tersebut. Bebas, makanan apapun yang Anda suka, tetapi tidak boleh rakus dan berlebihan. Di luar jam tersebut, Anda harus puasa, namun boleh minum air putih sesuai kebutuhan (tidak boleh ada kalorinya). Jendela makan 6 jam, Anda makan dari jam 1. Peraturannya sama seperti jendela makan 8. Jendela makan 4 jam, Anda boleh makan dari jam 1. Anda bisa atur waktunya sesuai kebutuhan. Peraturannya sama seperti jendela makan 8 jam dan 6 jam. Ada juga puasa 2. Bisa satu minggu sekali hingga 3 kali seminggu. Yang pasti, jendela makan dan puasa 2. Anda atur sesuai kebutuhan. Berarti tidak boleh sarapan? Yup, OCD tidak melarang Anda makan malam, tetapi tidak boleh sarapan. Banyak kontroversi seputar hal ini, namun dalam ebook OCD dijelaskan mengapa sarapan dilarang dalam OCD. Masih banyak hal- hal lain seputar diet OCD dalam 7. Deddy Corbuzier. Walaupun ada beberapa kontroversi seputar diet ini, banyak pelaku OCD yang mengirimkan testimonial dalam Twitter milik Deddy Corbuzier bahwa mereka menurunkan berat badan dan membentuk tubuh. Adakah sahabat Vemale yang sudah mencoba OCD?(vem/yel)- -- -Anda punya kisah inspirasi (cinta, pernikahan, persahabatan, keluarga, dll) atau punya tips keren seputar wanita? Silakan kirim ke redaksivemale@kapanlagi. Off Via Line (Only $2. P15.20- SPECTRUM ViaLine 1. Regulation 1272/2008/EC % weight CAS 123-86-4. The Reconnection Global Professional Practitioner Directory Join the Worldwide Network. Make your practice known. Online Level I: Feel The Frequencies. Try the new Google Patents, with machine-classified Google Scholar results, and Japanese and South Korean patents. Via Line is a food supplement that helps reduce weight through suppressing the appetite. These new products are lighter weight with improved performance compared to. Valine is an essential amino acid, which means that it cannot be manufactured in the body and must be obtained through dietary sources.
Note: Please note that if you are interested in a Ketogenic Diet used to treat Epilepsy or Pediatric Epilepsy, please start at Johns Hopkins who are the pioneers in. All product names, trademarks, registered trademarks, service marks or registered service marks, mentioned throughout any part of the MyDukanDiet.com web site belong. DASH Diet Recipes and Meal Ideas. Eating while on the Dash Diet is easy because the diet allows for an abundance of healthy food items. The Dash Diet is not a quick crash diet. You are making a lifestyle change when using this diet and eating healthy will be a long term commitment. Finding recipes that fit within the Dash Diet is also easy and many can be customized for your unique tastes. Try Rosemary Conley's Gi Hip & Thigh Diet food plan as an online exclusive. Find out more about the Rosemary Conley's Gi Hip & Thigh Diet, food plan and her diet book. The Fast Metabolism Diet by Haylie Pomroy (2013): What to eat and foods to avoid. 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Authors of the Dash Diet Cookbook, this site offers some great photos of all recipes with an abundance of other information about the Dash Diet. Dashdietoregon. org. This site offers a large collection of Dash Diet recipes for most all meals. This site is also a good resource of information on the Dash Diet. Thedashdiet. net. Easy to use site and lots of photos of the finished recipes. Some great ideas here for lunch with the Dash Diet. More About the Dash Diet. Hop on an indoor bike and burn off unwanted pounds at home or at the gym. You don’t have to worry about the weather when you choose to workout on an indoor bike. In fact, you can shed extra pounds even if you have yet to learn to ride a bike. You can just hop on, start pedaling, a burn hundreds of calories in every hour of working out. Likewise, you don’t have to worry about cars and other safety issues you’d encounter on an outdoor bike. Computerized stationary bikes typically have digital displays that let you know how many calories you’ve burned and how much distance you’ve covered. Some even have mechanisims for evaluating your heart rate and speed. If you prefer to have these calorie counts handy, a computerized model may be for you, but a non- computerized model will help you to burn calories just as well. Keep in mind that computerized calorie counters aren’t always accurate. If you select a computerized model, you may want to calculate your calorie burning on your own. This way, you can be sure that you are meeting your calorie burning goals. Upright or Recumbent Bikes. Upright bikes are similar to regular bikes. They are positioned with the pedals below you. A recumbent bike, on the other hand is designed so that your seat is semi- reclined when you’re on it and the pedals are not below you. Instead, they are position in front of your body. Often, people with lower back pain choose recumbent bikes because they provide support for the back and are easier on the knees. Which one you choose, whether for at home use or when you visit the gym, is up to you. Upright bikes can provide a more strenuous workout, but you can lose weight on both. In order to lose weight on an exercise bike, set aside some time to workout at least five times per week. If you’re just starting out, begin working out slowly. If yuou strain yourself, you will be in too much pain to want to workout the next day. Start with 1. 5 minutes on the bike, but understand that it’s okay to stop earlier if becomes too uncomfortable. Eventually your legs will get used to the workout and it will be more comfortable for you. In time, work up to 3. Once you are comfotrtable at level, work towards a goal of spending one hour on the exercise bike at least five days a week. As a beginner, it’s a good idea to start out with slower pedaling, eventually increasing your speed as your body is conditioned to your workouts. The same goes for resistance. Start with low resistance and plan to work up to a greater resistance level when you can do so without pain. Stationary Bike Workouts to Lose Weight. Working out on a stationary bike and following a. Fitness & ExerciseYou may be more likely to stick with your exercise bike workouts if you have some entertainment to keep you occupied. Some people watch television or listen to music to pass the time. How Effective Are They for Weight Loss? Exercise Bikes: How Effective Are They for Weight Loss? Find and save ideas about Stationary bike workouts on Pinterest. Bike Workout Best Exercise to Lose Weight. Minute Stationary Stationary Bike Workouts. How to Lose Weight on a Stationary Bike. Different Stationary Bikes for Weight Loss. The 3 Types of Exercise You Need to Lose Weight. You may even find that you enjoy reading on the bike, as long as you keep your balance and don’t fall off. To plan your workouts for maximum weight loss, start by figuring out how many calories you need to burn per day. If your goal is to lose 2 pounds per month, for example, you may need to burn about 3. As such, you may be able to meet your goal with little more than 3. Of course, the number of calories you burn will depend on how much you weigh and the intensity of your workouts. The faster you pedal and the greater your resistance, the more calories you will burn. Likewise, the more you weigh as you begin these exercises, the more you’ll burn in each session. In fact, you can shed extra pounds even if you don’t know how to ride an outdoor bike. Just hop on, start pedaling and burn hundreds of calories during every work out. Computerized or Non- Computerized Bike. To burn excess calories and tone your lower body, you can use either a computerized exercise bike or a non- computerized model. Computerized stationary bikes typically have digital displays that let you know how many calories you’ve burned and how much distance you’ve covered. Stationary Bike Exercise To Lose Weight What Is Good Book About Sugar Detox At Home Ways To Detox Your Body Has Anybody Take Renu Herbs Detox Tea Juice Detox For 5. This quality air-based stationary cycle comes with a pair of robust exercise arms for added caloric expenditure and overall comfort. This exercise bike is riddled. Check out my article and learn about stationary bike benefits for weight. I would like to lose 5 pounds. I just got a stationary bike that I. Weight Loss Exercise to Lose Weight. Pedal Away the Pounds Can a stationary bike get. How long do I need to go on the exercise bike a day to lose weight? Hi I had a baby 7 mths ago and have about 3 stone to lose. I just got an exercise. Some even have mechanisms for evaluating your heart rate and speed. If you prefer to have these calorie counts handy, a computerized model may be for you. However, a non- computerized model will help you to burn calories just as well. Keep in mind that computerized calorie counters aren’t always accurate. If you select a computerized model, you may want to calculate your calorie burning on your own. This way, you can be sure you are meeting your calorie- burning goals. Upright or Recumbent Bikes. Upright bikes are similar to regular bikes. They are positioned with the pedals below you. A recumbent bike, on the other hand, is designed so that your seat is semi- reclined when you’re on it, and the pedals are not below you. Instead, they are positioned in front of your body. Often, people with lower back pain choose recumbent bikes because they provide support for the back and are easier on the knees. Upright bikes can provide a more strenuous workout, but you can lose weight on both. Duration to Work Out. In order to lose weight on an exercise bike, set aside some time to work out at least five times per week. If you’re new to regular exercise, begin working out slowly. If you strain yourself, you will be in too much pain to want to work out the next day. Start with 1. 5 minutes on the bike, but understand that it’s okay to stop earlier if it becomes too uncomfortable. Eventually, your legs will get used to the workout, and it will be more comfortable for you. Gradually work up to 3. Once you are comfortable at this level, work towards a goal of spending one hour on the exercise bike, at least five days a week. Start Slowly. As a beginner, it’s a good idea to start out with slower pedaling, eventually increasing your speed as your body is conditioned to your workouts. The same goes for resistance. Start with low resistance and plan to work up to a greater resistance level when you can do so without pain. Entertainment. You may be more likely to stick with your exercise bike workouts if you have some entertainment to keep you occupied. Some people watch television or listen to music to pass the time. You may even find that you enjoy reading on the bike, as long as you keep your balance and don’t fall off. Working out for Weight Loss. To plan your workouts for maximum weight loss, start by figuring out how many calories you need to burn per day. If your goal is to lose 2 lbs. As such, you may be able to meet your goal with a little more than 3. Of course, the number of calories you burn will depend on how much you weigh and the intensity of your workouts. The faster you pedal and the greater the resistance, the more calories you will burn. Likewise, the more you weigh as you begin these exercises, the more you’ll burn in each session. 1000 Gaf Download Barnacle Lou Released: January 23, 2014 ! Grand Prizer Winner of 2009 Korean Animation. This domain is for sale! 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Continued How Is Inflammatory Bowel Disease Treated? Treatment for IBD involves a combination of self-care and medical treatment. Although no specific diet has been shown to prevent or treat IBD, dietary.Undifferentiated Connective Tissue Disease - In- Depth Overview - HSS. Jessica R. Berman, MDAssociate Attending Physician, Hospital for Special Surgery. Associate Professor of Medicine (Education), Weill Cornell Medical College. I was diagnosed with UCTD about 1 1/2 years ago but. I developed very severe stomach pain which was ultimately diagnosed as diverticulitis. Diet, all natural, gluten free everything. Two years ago i was also diagnosed with Sjogrens and UCTD. Late last year I started having chronic gut problems that I thought might be diverticulitis. The Mayo Clinic Diet Online; The Mayo Clinic Cookbook; Mayo Clinic on Alzheimer's Disease; Controlling High Blood Pressure; Mayo Clinic on Digestive Health; Diagnosis & treatment. Diagnosis; Treatment; Clinical trials. Learn more from WebMD about connective tissue disease, including symptoms and causes of various forms. Connective tissue diseases are actually a group of medical diseases. A connective tissue disease is any disease that has the connective tissues of the body as a primary target of pathology. Co- Director, Academy of Medical Educators, Hospital for Special Surgery. Assistant Program Director, Rheumatology Fellowship, Hospital for Special Surgery. Definition. Pathogenesis. Clinical Presentation. Laboratory Findings. Differential Diagnosis. Initial Treatment. Long- Term Management Issues. Prognosis. When to Seek Referral to a Specialist. Annotated Bibliography. I. But they don't have enough of such characteristics to meet the diagnosis for a well- defined connective tissue disease, such as rheumatoid arthritis, lupus, or scleroderma. Thus, they seem to have another, similar disorder that doctors call undifferentiated connective tissue disease. Connective tissue is the . It does not mean that your doctor does not know what to call what you have. This undifferentiated category is distinctly separate from another group of vague- sounding disorders called . However, because they may have features from several known diseases, they are said to be . Figure 1. The term undifferentiated connective tissue disease was first used in 1. CTD) but who did not yet meet the standard criteria for a well- defined CTD. At that time, it was noted that a substantial proportion of these patients remained undifferentiated – or experienced a disease remission – and never evolved in to a more defined rheumatic disease. Other names used early on to describe some of these patients included . As many as a quarter of all patients seen by rheumatologists have UCTD. Many researchers have been studying people with UCTD. They have been trying to identify serologic profiles (markers in the blood) that may predict who will eventually develop a well- defined connective tissue disease. They are also looking for markers to help predict whether the disease may go away, remain unchanged, or get worse. It is currently believed that less than 2. UCTD go on to develop a definite connective tissue disease. As many as one- third will experience a remission of their symptoms. The rest continue with generally mild disease in the undifferentiated form. Pathogenesis refers to the origin and development of a disease. The actual cause of UCTD, like many rheumatic diseases, is not well understood. Indeed, there have been no rigorous attempts to define the basic science of UCTD. It is presumed that many of the same immunologic mechanisms that play a role in lupus and rheumatoid arthritis may be involved. Theories in those diseases include a genetic predisposition, which is subsequently triggered by some environmental factor, such as an infection, that is improperly handled by the immune system. This in turn causes the immune system to be . Which of – or whether – these elements might be involved in UCTD remains unknown. UCTD will be difficult to study because it includes a heterogeneous population – people with so many different symptoms and blood markers. UCTD is not contagious. In the studies of patients that have been done to date, the most common symptoms of UCTD are: arthralgia (joint achiness); arthritis (joints that are swollen and hot, often with redness of the overlying skin; rashes, usually on the face, which can worsen due to sun exposure; alopecia (hair loss); Raynaud's phenomenon (color changes in your hands and feet in response to cold); oral ulcers (sores inside the mouth); xerophthalmia (dryness of the eyes due to decreased tears); xerostomia (dry mouth due to decreased saliva); low- grade fever (usually under 1. Some people also develop: leukopenia – decreased numbers of white cells (cells that help fight infection) in your blood; anemia – decreased numbers of red blood cells (cells that carry oxygen to tissues in the body) in your blood; thrombocytopenia – an abnormal decrease in the number of platelets (the parts related to blood clotting); pleuritis or pericarditis – inflammation of the lining surrounding the lungs or heart, respectively, which may cause pain in the chest, especially with breathing; neuropathy – abnormal nerve sensations, usually in the fingers or toes, ranging from numbness to tingling to pain. Problems with the kidneys, liver, lungs, or brain are almost unheard of in UCTD. The overwhelming majority of people with UCTD do not develop major organ damage or life- threatening disease. The hallmark of UCTD is its mild course and low likelihood of progression to a more serious state. There are no commonly accepted criteria yet for UCTD, as there are for many other rheumatic diseases. However, preliminary one has recently been proposed (See Mosca in Annotated Bibliography below) as follows: Preliminary Classification Criteria for UCTD Signs and symptoms suggestive of a CTD, but not fulfilling the criteria for any of the defined CTDs, for at least three years. Presence of ANA identified on two different occasions(ANA refers to antinuclear antibodies found in the blood. These markers may indicate that your immune system is forming antibodies to parts of your body.)At the present time, UCTD is diagnosed clinically by your doctor when the symptoms, labs and history fit the . It is not based on meeting a checklist of required . As doctors develop more specific criteria for UCTD, however, it will be easier to study the disease and learn about its causes and best treatments. A. Immunologic. Some markers in your blood indicate possible abnormal function of your immune system. While most studies note that the majority of patients with UCTD are have antinuclear antibodies (ANA), a broad range of immunologic abnormalities can be seen in people with UCTD. These may include: elevated erythrocyte sedimentation rate (ESR - an indicator of inflammation); antiphospholipid antibodies (which can affect blood clotting and may increase your risk of miscarriage),hypergammaglobulinemia (an excess of gamma globulin, often called Ig. G, a protein in the blood that's involved in resistance to infection); hypocomplementemia, (a decreased level of complement – proteins that help destroy bacteria and other cells – commonly referred to as C3 and C4); a false positive blood test for syphilis, known as . Hematologic. As noted above, several blood disorders – thrombocytopenia, leukopenia, and anemia – may also occur in patients with UCTD. They are rarely severe enough to require treatment alone. C. Predictive Value of Laboratory Findings. Research has attempted to determine which, if any, of the laboratory test findings may predict the evolution of UCTD to lupus or other connective tissue diseases. In a study of 1. 48 patients who had detectable anti- Ro/SSA antibodies and a diagnosis of UCTD for at least one year, leukopenia was more frequent in those patients who ultimately developed a defined connective tissue disease. Anti- ds. DNA antibodies were predictive of evolution to SLE. However, the majority of patients in this study who developed a connective tissue disease progressed to primary Sjogren's syndrome (5. Another study found that anti- RNP antibodies were significantly correlated with Raynaud's phenomenon and arthritis. Anti- Ro antibodies also correlated with dry eyes and dry mouth. Most interestingly, 8. The serologic profile of these UCTD patients remained unchanged in follow- up. Among those UCTD patients with features more suggestive of lupus (termed incomplete lupus), it has been noted in a group of 8. DNA and decreased C4 (one type of complement) were associated with subsequent development of lupus. Others have noted that the presence of homogeneous ANA (one of several . One study followed 4. UCTD; it found that 2. Similar studies have suggested that the rate of progression might be even higher. If you are worried about this, your doctor – or a doctor to whom you are referred – can examine your nailfolds under a microscope. However, nailfold capillary abnormalities have been seen in many other diseases, such as dermatomyositis, lupus, and Sjogren's syndrome, and psoriasis. It is always wise to discuss your laboratory tests with your doctor and ask for explanations of what they mean. You may want to ask for copies of your test results to keep in a folder at home so you can see how they change – or do not change – over time. Many different diseases can cause symptoms similar to those of UCTD. Differential diagnosis is the process by which the physician figures out which one is causing your problems. This is important because diseases that may cause such symptoms are often treated in a very different manner from UCTD. Other well- defined connective tissue diseases that need to be considered in the process of differential diagnosis include: rheumatoid arthritis, systemic lupus erythematosus (SLE), myositis, Sjogren's Syndrome, and scleroderma. Diffuse body pain without other objective features, even in the presence of a positive ANA, argues more strongly for fibromyalgia than a true connective tissue disease. A thorough history, exam and laboratory evaluation to rule out these other rheumatic diseases is important. In this sense, the diagnosis of UCTD is one of exclusion. When the suspicion of an autoimmune disease is high in a patient because several features of one or more of these diseases is present, but signs and symptoms are insufficient to meet their criteria, UCTD is diagnosed. However, the threshold for reconsideration of a more definite CTD must be low if, and when, new symptoms present in such patients. No formal study of various treatments in patients with UCTD has been conducted. Most therapies are borrowed from physicians' experiences of their effectiveness in other rheumatic diseases. However, it is unknown to what degree a particular therapy improves the symptoms of UCTD or decreases the rate of flare or the likelihood of evolution to a more defined connective tissue disease. |
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November 2017
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