Wednesday, July 30, 2014

(LML) Where are training courses provided for training in basic leprosy and leprosy microscopy?

Leprosy Mailing List – July 30,  2014 

Ref.:   (LML)  Where are training courses provided for training in basic leprosy and leprosy microscopy?

From:  Miriam Pahun, Port Moresby, Papua New Guinea


 

Hi Pieter,


Could the Leprosy Mailing List Readers help me and advise on the following:

I planned to have three of my government officers for training on Basic leprosy training and leprosy microscopy training this year for 4-6 weeks.

If anyone have any update information on the training Institutions  and the contact address where I can contact them for the training of my officers.

With this, thank you and looking forward to your reply soon.

Best regards,

Miriam

miriam_pahun@health.gov.pg


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com




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(LML) Staining of M. leprae

Leprosy Mailing List – July 30,  2014 

Ref.:  (LML) Staining of M. leprae 

From:  P.K. Das, Birmingham, U.K.


Dear Pieter,

Thank you for the letters of David Schollard  and Jaison Barreto (LML July 25, 2014).

Variable results in  Fite vs ZN staining is well recognised. In order to overcome such difficulty, I wonder whether or not one should advocate the staining with specific LAM and PGL-1 antibodies, which is quite easy at least not more difficult than Fite  and ZN.

In regards to Jaison’s  remark, I fully sympathise with his compassion. However, in regards to the dogma that M.leprae has affinity for Schwann cells and the notion that once infected M.leprae goes to Schwann cells, I question if it is really absolute correct or does M.leprae hide away from the rising immune attack by the host and take refuge in Schwann cells in face of the immune attack.

My experience with Patricia Rosa in ILSL, who carries out routinely mouse foot pad inoculation, is that to my knowledge we were not able to find any AFB in the nerves or Schwann cells adjacent to the foot pad site where the bacilli were multiplying.

One should carefully reconsider this dogma. Most likely David may comment on this.

 

Regards,


Pranab


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com




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Tuesday, July 29, 2014

(LML) Staining or PCR detection of M. leprae

Leprosy Mailing List – July 29, 2014 

Ref.:   (LML)  Staining or PCR detection of M. leprae

From:  Norihisa Ishii and Koichi Suzuki, Tokyo, Japan


Dear all,

We noticed that some technical issues are occasionally discussed in LML, such as the staining or the PCR detection of M. leprae. We would like to share some information about the laboratory diagnosis of leprosy that is performed in our lab at the Leprosy Research Center, National Institute of Infectious Diseases, Tokyo, Japan.

We are routinely performing the following examinations:
 - histopathological staining of paraffin sections (H&E, Fite staining, S100 immunostaining, and others if necessary)
 - staining of acid-fast bacilli using a slit-skin smear samples on a glass slide
 - detection of serum PGL-I antibody titers
 - PCR detection of M. leprae genes from slit-skin smear, tissues or paraffin sections

In Japan, we are responsible to perform the above tests for differential diagnosis of leprosy as a part of government service with free of charge. We are willing to provide the above laboratory examinations for samples from all the countries if they are sent appropriately. Please consult Dr. Norihisa Ishii or Dr. Koichi Suzuki for further inquiries.

With kind regards,

Norihisa Ishii (
norishii@nih.go.jp)
Koichi Suzuki (
koichis@nih.go.jp)

 


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com




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(LML) Staining smears for leprosy

Leprosy Mailing List – July 29,  2014 

Ref.: (LML) Staining smears for leprosy

From:  Andrea Clapasson, Genoa, Italy


 

Dear Pieter,

Thank you very much to you and your colleagues for the good job done with the leprosy mailing list.  I refer to your last mails about the important topic of staining of M. leprae.  Herewith are my comments.

There are different methods for staining but each method must be standardized by the single laboratory.

Several authors tell that they are using a Ziehl-Neelsen stain but this affirmation is too simple and, it is not clear.  Can a simple name (Ziehl-Neelsen’s method) create confusion?  Yes, it can, only after a carefully reading of the relevant papers it is possible understand the used procedure.  The methods reported as Ziehl-Neelsen are:

a.         Classical Ziehl-Neelsen’s method;  here the slide is warmed before to wash it by acid-alcohol solution;

b.         The Kinyoun staining, where the slide with sample is not flamed and it is known as cold Ziehl-Neelsen technique.  Personally I prefer this procedure (Fandinho FC and other Int J Lepr Other Mycobact Dis. 1990 Jun;58(2):389-91)

c.         Fite-Wade-Faraco

 

The critic steps are:

  • concentration of the Primary stain
  • volume of solution acid-alcool used in the destaining
  • concentration of  acid in the destaining solution
  • time exposition at Primary stain
  • the critic step you can evocate for counter stain (concentration of blue methylene, its concentration, time ……)

 

If you read papers on this subject since 1915 you find so many changes and modifications one after the other that at times you lose the original work, new modifications not always provide relevant improvements and sometimes quality is lost.  Below are reported two papers that I regard as most valuable if you want to use Carbolfucsine for looking for M. leprae the reference article is the following one:

-           A comparison of the Ziehl-Neelsen and Kinyoun methods in staining smears from leprosy patients. Fandinho FC, Orsi-Souza AT, Salem JI. Int J Lepr Other Mycobact Dis. 1990 Jun;58(2):389-91.

Furthermore the following article it is of great interest:

-           Inefficiency of 0.3% carbolfuchsin in ziehl-neelsen staining for detecting acid-fast bacilli. Selvakumar N, Rahman F, Rajasekaran S, Narayanan PR, Frieden TR. J ClinMicrobiol. 2002 Aug;40(8):3041-3.

 

Herewith follows a description of the method I use in Genoa.

Cold Ziehl–Neelsen technique for slit-skin smear (SSS) and nasal swab (NS)

[Kinyoun staining]

1.         Cover the sample (skin smear o nasal swab) with primary stain (*), for 20 minutes;

2.         rinse gently with indirect stream of tap water, until the water flows off clear;

3.         decolorize each slide separately with 2,5 ml of solution of hydrochloric acid and ethanol or sulphuric acid and alcohol (**). This step is more critical of all procedure, because M. leprae is more easily decolourized than other mycobacteria, for example of M. tuberculosis. If duration of destaining is too long there are false negatives while if it is too short there are false positives.

4.         rinse with indirect stream of tap water;

5.         counter stain with methylene blue 1% (***), for 30 seconds;

6.         rinse the stain with indirect stream of tap water until the water flows off clear;

7.         allow slides to dry, away from sunlight;

8.         observe the slides under oil immersion.

 AFB appear red, while non-AFB other organisms and cellular materials appear blue.

 

(*) Primary stain:

a.         in a beaker previously weighed dissolve 6.75 g of basic fuchsin in 67.5 g absolute alcohol.

b.         Add 37.5 g of 5% aqueous phenol. [phenol solution: weight 5 g of phenol crystal and dissolve them in 100 ml distilled water (heating gently)]

c.         After add deionised water up to 675 g.

d.         Mix well and filter before use.

Prepare the solution with all components under the fume hood, using appropriate safety equipment (gloves, mask for dust and fumes). The prepared solution is transferred in dark glass bottle with screw cap (capacity one liter). Label bottle with name of reagent as well as preparation and expiry dates. Store at room temperature for six to twelve months.

 

(**) Decolorizing reagent: 95ml ethanol 96° and 1ml hydrochloric acid 37% (fuming).  Important: you must always add acid, drop by drop, to solvent, not vice versa.

In countries where the acquisition of alcohol may be problematic, an aqueous solution of 23,75% sulphuric acid and 3% alcohol may be used as decolourising agent. This is prepared as follows: add 25 ml of 95% sulphuric acid slowly (not vice versa) to solution of 71,5 ml of distilled water and 3,3 ml of 90% denaturized alcohol.

 

(***) Counter stain: dissolve 1g methylene blue in 100 ml distilled water.

Many mycobacteria can survive and grow in nutritionally poor environments such as water puddles and even chlorinated tap water.  Environmental mycobacteria might be present in the tap water; boiled water does not solve the problem, you will kill them but they will appear again as AFB after staining. The water is a reagent and its quality is the most important thing, use purified or distilled water for your solution, not tap water, rain water or boiled water.

If it is possible include one positive and one negative control among the slides when you are staining, for the quality control of Ziehl-Neelsen reagents.

 

Andrea Clapasson

 


LML - S Deepak, B Naafs, S Noto and P Schreuder
LML blog link:
http://leprosymailinglist.blogspot.it/
Contact: Dr Pieter Schreuder <<
editorlml@gmail.com

 




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Friday, July 25, 2014

(LML) Staining of M. leprae vs. M. tuberculosis and decolorizing with hydrochloric acid

Leprosy Mailing List – July 25, 2014 

Ref.: (LML)    Staining of M. leprae vs. M. tuberculosis and decolorizing with hydrochloric acid  

From:  David M. Scollard, Baton Rouge, Louisiana, USA


Dear Pieter,

The two images (see attached file) illustrate our experience with the issue of Fite vs ZN staining for M. leprae. 

The ZN stain was performed by a very good laboratory, and no AFB were seen in this section sent to us.  They also sent a positive control slide (M. tuberculosis) in which AFB were clearly stained.

The Fite stain was performed in the NHDP laboratory on another section from the same block. Many AFB are seen.

This is an extreme example, but illustrates the point. The exact details of ZN staining and decolorization vary between laboratories.  We often see fewer bacilli with a ZN stain than with a Fite stain, but it is unusual to see the total lack of staining of M. leprae with the ZN stain as in this case. 

These images are in a review that has been submitted for publication.

 

David M. Scollard, M.D., Ph.D.

Director

National Hansen’s Disease Programs

Tel:  225-756-3713 (Clinical) or 756-3776 (Administration)

Fax:  225-756-3819 or 756-3806

E-mail:  dscollard@hrsa.gov

Web:  www.hrsa.gov/hansensdisease  


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com

 




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(LML) Staining of M. leprae vs. M. tuberculosis and decolorizing with hydrochloric acid

Leprosy Mailing List – July 25,  2014 

Ref.:   (LML)    Staining of M. leprae vs. M. tuberculosis and decolorizing with hydrochloric acid 

From:  Jaison Barreto, Bauru, São Paulo, Brazil


 

Dear Pieter

 

There are many problems in the field, concerning to the laboratory confirmation of leprosy diagnosis. All of them comes from the lack of knowledge about the disease. How many professionals know what is Ridley & Jopling Classification today? Or even Madrid Classification? Or Indian Classification? Leprosy becomes a question of "number of lesions". According to this "scientific classification", diffuse infiltration with no visible lepromas (lepra bonita) is not leprosy. And if the patient has only 1 to 5 visible lepromas, shall we classify this person as having PB leprosy? Pure neural leprosy does not exist in this classification. A patient with reaction before MDT is MB, and if the reaction occurs after the start of MDT, this patients will be misclassified as being "PB with reaction"!!! This is an absurd.

 

Many physicians think that leprosy is a skin disease, and just do not know that it is primary from Schwann cells. Indeterminate (or initial) leprosy, with only non myelinated nerve fibres involvement, is very rare, almost always restricted to young children. Also, true Tuberculoid (TT) patients usually does not seek for medical assistance, once the disease is asymptomatic and evolves to self healing. 

 

So, what is the class of patients who we will find, in most instances? Borderline or Lepromatous ones. This group of patients are, indeed, multibacillary, once the disease was not self limited, due to the lack of resistance, partial or total. It is not uncommon to find initial Borderline patients, when the slit skin smears are negative in index points, and sometimes even in the lesions, but many bacilli are hidden inside the cutaneous nerve trunks (sanctuary). As nobody takes a biopsy specimen from cutaneous nerve branches, by ethical reasons, these patients are often misclassified as having PB leprosy, i.e., BT leprosy. Unfortunately, when treated with this regimen, often they suffer for several years from type 1 reaction, and finally a "relapse" occurs, usually after 7 to 10 years. Why should we treat a patient BT with 5 lesions with MDT PB, and with MB another one with 6 lesions? Both have partial resistance to the bacilli, i.e., have the same prognosis!!!

 

Some people, whose defend this classification could say: "Oh, but this classification was based on several papers, when it was observed that most patients with 6 or more lesions had slit skin smears positive, different from those with 5 or less". The question is only one: what is the quality of bacilloscopy in the world? How many laboratories know that staining of leprosy biopsies must be done with Faraco-Fite, and not with Ziehl-Neelsen? 

In the last 7 years, I have been in the field, at least once a month, training health professionals. At the Brazilian state of Mato Grosso do Sul, where bacilloscopy was thought to be almost perfect, i.e., 99% of concordance between the evaluation of the slide in the field and in the state reference, we saw that, indeed, 84% had problems during the process: collection, staining, quality of dyes or interpretation. Bacilloscopy of ear lobes, knees and elbows, only, does not mean that in the lesion (or inside the nerve) there are no bacilli. And, as collection of slit skin smears from the lesions is often difficult to do, usually it is not collected from these sites.

 

Last year, I observed the same problem in 2 different countries, Brazil and Russia: in the state of Mato Grosso, the highest endemic state on leprosy in Brazil, and also in the reference center in Russia. The staining for M. leprosy just did not work, because the biopsy sections were deparaffinized with pure xylol (Ziehl), instead to use oil added to xylol (Faraco-Fite). The result is a catastrophe: negative for AFB, in all Borderline cases, and sometimes even in Lepromatous leprosy.

 

It could be better to forget this pseudoclassification of PB and MB. Once true TT and Indeterminate leprosy is not common, the question is: "Why not to treat all patients with MDT MB, giving a second cycle to those that did not show a complete remission?". I am sure we would avoid many "relapses", sequelae and suffering.

 

 

Regards,

 

 

Jaison Barreto

ILSL, Bauru, Brazil


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com




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Tuesday, July 22, 2014

(LML) Questionnaire about information needs regarding NTDs (including leprosy) and cross-cutting issues

Leprosy Mailing List – ,  2014 

Ref.:    (LML) Questionnaire about information needs regarding NTDs (including leprosy) and cross-cutting issues.

From:  Ilse Egers, NLR/Infolep, The Netherlands


 

Dear Colleagues,

 

The Netherlands Leprosy Relief (NLR) is operating Infolep, a portal with access to digital information resources on leprosy and related subjects. Infolep facilitates free access to information for anyone involved in leprosy, from researchers to students, and from to programme-managers to fieldworkers.

 

Because leprosy is one of the Neglected Tropical Diseases (NTDs), we are considering to expand the free services of Infolep to meet so far unmet information needs within the NTD community. The scope of the portal might be broadened with NTDs and cross-cutting issues related to Morbidity Management and Disability. These would include topics such as: community awareness, disability prevention, patient education, self-care, wound-care, physical and socio-economic rehabilitation, community participation, stigma and discrimination, NTD-related mental health problems.

 

To gain more insight in this question, we set up a questionnaire about information needs regarding NTDs and cross-cutting issues.

 

You are invited by NLR/Infolep to fill in this questionnaire before 31 July, but it would be also very helpful if you would pass on the link to other persons/organizations that might be interested to share their views with us on potential need for an NTD cross-cutting issues related information portal.

 

Please follow this link to the questionnaire: https://nl.surveymonkey.com/s/NTDcrosscuttingissues

 

 

Thank you very much in advance for your cooperation.

 

 

With kind regards,

 

 

Ilse Egers

 

Medewerker InfoLep / Information Officer

 

Infolep Leprosy Information Services

 

Postbus / P.O. Box 95005

1090 HA Amsterdam

The Netherlands

Tel:

+31 20 5950500

Email:

I.Egers@Leprastichting.NL

Web:

www.leprosy-information.org

 


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com




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Friday, July 18, 2014

(LML) Staining of M. leprae vs. M. tuberculosis and decolorizing with hydrochloric acid

Leprosy Mailing List – July 18 ,  2014 

Ref.:  (LML)    Staining of M. leprae vs. M. tuberculosis and decolorizing with hydrochloric acid

From:  Richard de Soldenhof,Edinburgh, Scotland


 

 

Dear Pieter,

 

 

Dr. Ben Naafs’ comment reinforces the need to ensure that the Ziehl-Neelsen (Z-N) staining procedure on leprosy skin smears is not too robust. As pointed out by Dr. Noto, it has long been stated that M. leprae is more easily decolourised than M. tuberculosis, and hence the 2 commonly used decolourisers, (1% hydrochloric acid in 70% ethanol or 5% sulphuric acid, for M. leprae) are both weaker and are applied to the slide for a shorter period, than for M. tuberculosis.

 

Our paper,  “Choosing the decolouriser and its strength to stain Mycobacterium leprae. Does it matter?” (de Soldenhoff, Hatta and Siro), in Lepr. Rev. 1998 June; 69(2): 128-133,  answered this question with a  “no”, but Naafs’ report suggests that it is “yes”.  It would be of use to have further studies to further clarify this. The other points made in our paper, however, do justify repeating:

 

• Most new leprosy patients can be competently diagnosed and commenced on appropriate treatment without a skin smear. However, there are some patients who present with single or few lesions, but who have early multibacillary disease. A positive skin smear will be found in some of these patients and this means MB MDT is needed.



• There are other patients, either new or old, who have no clearly demonstrable clinical cardinal signs, but who have a positive smear. In new patients this confirms the diagnosis of multibacillary leprosy; in previously treated patients, it may suggest relapse and a repeat course of MB MDT may be indicated.



• With fewer leprosy patients in a programme which has been officially eliminated, the taking, staining and reporting of leprosy slit skin smears has, in many cases, become a lost art. On the other hand, laboratories at sub district level are usually carrying out Z-N staining for tuberculosis, and there is often a quality control system in place for this.



• Even if the staining technique is not identical, the comparatively small leprosy workload (compared to that for tuberculosis) should make it possible for the same laboratory staff to do both procedures, and of reasonable quality. Taking a skin smear should be within the competence of leprosy field supervisors, as well as of laboratory staff.




Dr. Richard de Soldenhoff,

formerly Leprologist with NLR,

Edinburgh, Scotland, UK

 


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com

 




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Wednesday, July 16, 2014

(LML) M leprae and M tuberculosis acid-fastness

Leprosy Mailing List – July 16,  2014 

Ref.: (LML)   M leprae and M tuberculosis acid-fastness

From:  Salvatore Noto, Bergamo, Italy



Dear Ben and Pieter,


Thank you for your message (LML July 9, 2014). M. leprae and M. tuberculosis are two acid-fast bacilli. They both show resistance to decolorization by acids but, old leprosy books report that their resistance (acid-fastness) is different.


During a first step of the Ziehl–Neelsen stain they are stained red. Then M. tuberculosis resists to decolorization with 3% hydrochloric acid [and keeps the red colour] while M. leprae resists only to a lower percentage. In this case to avoid decolorization and keep M. leprae red and visible, a 1% concentration is needed.


Old leprosy literature reported this concept. Sir Leonard Rogers and Ernest Muir in Leprosy, Third Edition, London 1946, page 220: “It must be remembered that leprosy bacilli are less acid-fast than tubercle bacilli”.  Anthony Bryceson and Roy E. Pfaltzgraff in Leprosy, Third Edition, London 1990, page 63 again reminds the reader of the same. In Leprosy, A Practical Guide, Springer-Verlag Italia 2012, Andrea Clapasson and Silvia Canata, page 58, specifically mention that “Decolorize each slide separately. This is the most critical step of the whole procedure, because M leprae is more easily decolorized than other mycobacteria, for example M tuberculosis. If the duration of the destaining is too long, false negatives may occur, while too short a period could result in false positives”. May be Andrea can comment on this (both on the concentration and the duration of the decolorization)?

 

Salvatore


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com




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(LML) Staining of M. leprae vs. M. tuberculosis and decolorizing with hydrochloric acid

Leprosy Mailing List – July 16,  2014 

Ref.:   (LML)  Staining of M. leprae vs. M. tuberculosis and decolorizing with hydrochloric acid

From:  Jpseph Kawuma, Kampala, Uganda


 

Dear Pieter,

 

 

Thank you for the important eye-opener in Dr. Ben Naafs' case report LML July 9, 2014I think that the knowledge and skills for skin smear microscopy might be disappearing even faster than other leprosy related skills.

 

Do you know if there are facilities where existing staff (especially of National reference Laboratories) could be trained in appropriate skin smear techniques?

 

 

 

H Joseph Kawuma

GLRA, Uganda

 

 


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com




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Wednesday, July 9, 2014

(LML) Staining of M. leprae versus M. tuberculosis and decolorized with hydrochloric acid

Leprosy Mailing List – July 9,  2014 

Ref.:    (LML)  Staining of M. leprae versus M. tuberculosis and decolorized with hydrochloric acid

From:  Ben Naafs, 


 

 

Dear dr Schreuder,

 

I like to share an important supportive finding confirming and reinforcing dr Jaison Barreto’s remark on the staining of M. leprae.

 

Like each year I teach at the Regional Dermatology Training Centre (RDTC) in Moshi Tanzania, which is a WHO reference center for leprosy. We train Dermatology residents and students in an Advanced Diploma in Dermatology and Venereology (ADDV) in African Dermatology, STD and leprosy.

                                                                 

Case report:

A 65 years old man visited the center because he was diagnosed with a positive skin smear in a former leprosarium where the old laboratory technician did a skin smear and found him to be 2+ positive. Since the knowledge on clinical leprosy, even in an endemic country like Tanzania, is disappearing, the Health Officer searched for conformation at the RDTC. There the attending clinician thought it could be leprosy and wanted this confirmed with a smear. The local facilities were out of order and he asked the International TB research center to do the staining and got the results back. Smear negative.

 

I was asked to see the patient: Clinically clearly a subpolar leprosy patient. I asked again a smear and checked the way the staining was done. The TB technician coming from and trained in a western country decolorized with 3% hydrochloric acid like for M.TB, instead of 1% hydrochloric acid for a short time for M. leprae. The repeated smear, now with only 1% gave a BI: 4, showing that the smear for leprosy should be different from that for tuberculosis. It is well possible that since the interest in leprosy following the proclaimed elimination of this disease is diminished, many leprosy patients have erroneously been misclassified or misdiagnosed. 

 

 

With regards,

 

dr Ben Naafs

 


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com




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Saturday, July 5, 2014

(LML) An article on leprosy from the New York Times on July 1, 2014

Leprosy Mailing List – July 5,  2014 

Ref.:  (LML)  An article on leprosy from the New York Times on July 1, 2014

From:  Judith Justice, Berkeley, California


 

Dear Pieter,  

 

Attached is a link and downloaded file copy of an article on leprosy from the New York Times on July 1, 2014.  

 

With many thanks,

Judith Justice

 

 

Begin forwarded message:

 

wouldnt want you to miss this

 

Sent by susangoldstein@earthlink.net:

Leprosy, Still Claiming Victims

By NATALIE ANGIER

New research suggests that the leprosy parasite is a paradox encapsulated at once rugged and feeble, exacting and inept.

Or, copy and paste this URL into your browser: http://nyti.ms/1k753WM


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com




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