Wedding Ring allergy

14 Jun 2012 Leave a Comment

by lynnawiensmd in Contact Dermatitis & Patch Testing, Newsworthy items, Skin rashes, What's New in the Office? Tags: , , , , ,

Think you can be allergic to your spouse? Just this week in the clinic, a middle-aged woman presents with a rash found only when she wears her wedding ring.  No other jewellery gives her problems except for the ring when worn > 2-3 days.  Although nickel allergy can cause this scenario, this woman probably has occlusion dermatitis or “wedding ring allergy.”  Any accumulation of soap and water underneath the ring will cause this type of dermatitis in sensitive individuals.  Want to learn more? 

http://www.medicinenet.com/script/main/art.asp?articlekey=107570

Are CT scans dangerous?

13 Jun 2012 Leave a Comment

by lynnawiensmd in Newsworthy items, Sinusitis, What's New in Medical Literature? Tags: ,

Research does demonstrate that in children, CT scans can lead to a small, but measurable increase in the risk of cancer.  How does one protect your child, yet obtain the x-rays that will give the proper diagnosis and are clinically indicated?

  1. I am of course referring to a CT (coronal) scan of sinuses used to diagnosis infection or anatomical nasal obstruction.  Many patients need CT of sinuses because the underlying cause of their runny nose has never been identified.
  2. Fortunately, coronal CT of sinuses exposes children to very little radiation because the area that is examined is very small (just the face)
  3. Coronal CT of sinuses does not require repeated examinations.  Once is usually enough!
  4. Usefulness of a plain sinus x-ray is questionable.  False negative rates (study is normal, but wrong) can be as high as 30-40% with a plain radiograph.  Take home message: benefit isn’t worth the risk.

Read the article below, but you probably don’t need to worry about CTs of the sinuses. 

http://www.usatoday.com/news/health/story/2012-06-07/childrens-ct-scans-cancer/55439406/1

Improvement in survival without new drugs!

11 Jun 2012 2 Comments

by lynnawiensmd in Just For Fun! And you might learn something too!, Natural products for allergies, What's New in Medical Literature? Tags: , , , , , , ,

Truly remarkable how cancer survival has improved in children WITHOUT the addition of new drugs.  There is so much more to health than just taking more medication!  Allergy operates in the same way–good avoidance is first, followed by other aggressive medications.

http://www.usatoday.com/news/health/story/2012-06-04/childhood-cancer-progress/55333892/1

Are We Overreacting?

31 May 2012 Leave a Comment

by lynnawiensmd in Asthma, Newsworthy items, What's New in Medical Literature? Tags: , , , , , , ,

The Journal of Allergy and Clinical Immunology
Volume 129, Issue 5 , Pages 1280-1281, May 2012

Thanks Dr Pedersen for your insight!  The bottom line: maybe combination Advair, Symbicort, or Dulera aren’t as bad as they are put out to be. 

Over the last decade, the aims of asthma management have altered to focus on achieving and maintaining good asthma control and reducing future risks, such as decrease in lung function, asthma exacerbations, hospitalizations, death, and adverse effects from treatment.  The benefits of good asthma control include a variety of asthma outcomes that are important to both patients and society.

These include:

  • No restriction in lifestyle
  • Better physical fitness and quality of life
  • Reductions in patients’ perception of the asthma burden, health care resource use, and lower risk of exacerbations, hospitalizations, and death.

Inhaled corticosteroids (ICSs) or combination therapy with an ICS and a long-acting β2-agonist (LABA) have become established as cornerstones in guideline-recommended asthma treatment because these therapies have been the most successful in achieving asthma control and reducing future risks in the vast majority of patients with asthma. 

Changes in the goals of asthma management, as well as treatment recommendations, have revolutionized management from both the patient’s perspective and a societal perspective. The main question that remains is whether the clinical benefits balance or outweigh the risks of the treatments?

When regular ICS treatment was introduced 4 decades ago, safety concerns were common, and initially, the treatment was reserved for patients with severe disease. The concerns were based on fears generated by the side effects of oral corticosteroids rather than data generated by using ICSs, but with increasing knowledge and experience, the concerns decreased, and ICSs became a first-line therapy for asthma because the benefits of the treatment clearly outweighed the risks.  Fast foward to 2012 and our concern is overuse of combination therapy with LABAs/ICS as a risk factor for severe, albeit rare, severe asthma exacerbations. 

In this issue of the Journal of Allergy and Clinical Immunology, Wells et al add to the paucity of real-world data by reporting the findings from a large, population-based, real-world observational study comparing the effects of ICSs and fixed-dose ICS/LABA combination therapy on severe asthma exacerbations in a racially diverse population of 1828 patients with a total of 3791 person years of follow-up. Data were obtained longitudinally from a managed care organization, and LABA exposure was estimated from pharmacy data. It was found that ICS/LABA combination therapy had an overall protective effect on asthma exacerbations that was as good as or better than that for ICSs alone. The protective effects of ICS/LABA combination therapy seemed particularly marked in patients older than 18 years, male subjects, patients with moderate and severe asthma at baseline, and reassuringly, African Americans (who have been suggested to be at greater risk).

Although the study is well executed, carefully analyzed, and uses sound methodology, it was not of a sufficient size to make any firm conclusions about severe but rare asthma-related events, such as intubations, death, or both. Yet it is an important contribution to the literature on the perceived risk of serious adverse effects of LABAs. It is reassuring that the results from a carefully executed observational study, mimicking real-world study conditions, are in such good agreement with the findings in the randomized, controlled efficacy trials comparing ICS use alone with a fixed LABA/ICS combination.  In addition to significant improvements in asthma control, such studies consistently report reductions in asthma exacerbations, need for oral steroid bursts, and asthma-related emergency department visits compared with ICS treatment alone. Because such events normally precede more serious outcomes, such as intubations, death, or both, these findings make it unlikely (but do not prove) that treatment with fixed LABA/ICS combinations per se should be associated with an increased risk of these serious outcomes.

The US Food and Drug Administration has requested a series of very large postmarketing clinical trials to evaluate LABA/ICS combination safety, (see reference below) but the most serious asthma outcomes are so rare that even these studies might not be able to provide a definite conclusion. Moreover, the results from these studies will not be available until 2017 at the earliest. What should clinicians do in the meantime?

It would be a disservice to our patients if we, in the fear of doing harm to our patients, waited for the perfect. The study by Wells et al supports that a better option would be to follow the recommendations of the asthma guidelines, which unanimously have taken the stand that there is no convincing evidence that LABA/ICS combinations administered in a single inhaler are associated with serious adverse effects. Their benefits on asthma control and reduction of asthma exacerbations outweigh their risk, and we should be careful not to let the perfect become the enemy of the good.

Chowdhury BA, Seymour SM, Michele TM, Durmowicz AG, Liu D, Rosebraugh CJ. The risks and benefits of indacaterol—the FDA’s review. N Engl J Med. 2011;365:2247–2249

The More You Know, the Less You Know

28 May 2012 2 Comments

by lynnawiensmd in GERD or reflux, What's New in Medical Literature? Tags: , , , , , , ,

The practice of medicine is just that….I advise the recommended treatment based on the information available at the time.  If I look back to the time during my fellowship in the early 90′s, much of what we thought was true and now 20 years later, been disproven.  As an example, the following study from a respected medical journal cautions against the use of PPI medication for reflux in children.  It’s worth your attention, but first some background information.

Children have a high prevalence of asthma and gastroesophageal reflux (GER). Children with asthma often report symptoms of GER and also have a high prevalence of asymptomatic GER.  We call this “silent reflux”. 

Some experts have suggested that untreated GER may cause persistent asthma control problems in children refractory to treatment with inhaled corticosteroids. However, whether treatment with proton pump inhibitors (PPIs) improves asthma control has not previously been determined. The objective of this study by Holbrook and colleagues was to determine whether lansoprazole is effective in reducing asthma symptoms in children without overt GER.  (ie, Prevacid for “silent reflux”)

Study Synopsis and Perspective

Use of PPIs in children with poorly controlled asthma who were using inhaled corticosteroids and who had no symptoms of GER was not found to improve asthma control and was, in fact, associated with an increase in adverse effects, according to results of a study published in the January 25 issue of JAMA. (PPIs Produce Negative Outcomes in Children With Poor Asthma Control)

PPIs ”are often prescribed for poorly controlled asthma regardless of reflux symptoms, and there have been large increases in the use of PPIs among children between 2000 and 2005…. Hence, it is of clinical importance to determine whether antireflux therapy, the most common of which are PPIs, improves control of asthma in children,” write Janet T. Holbrook, MPH, PhD, from the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, and colleagues from the Writing Committee for the American Lung Association Asthma Clinical Research Centers.

The goal of this placebo-controlled, double-masked, randomized study was to determine whether the PPI lansoprazole was effective in controlling asthma symptoms in children with asthma, but no overt GER. The researchers also investigated whether pH testing would identify children with GER who responded to PPI therapy.

The children were randomly assigned to receive either lansoprazole (15 mg/day for those weighing <30 kg; 30 mg/day for those weighing ≥30 kg; n = 149) or a matching placebo (n = 157). The researchers found that the mean difference in the Asthma Control Questionnaire (ACQ) score between the 2 groups was 0.2 units (95% confidence interval [CI], 0.0 – 0.3 units), which was not statistically significant (P = .12).

There also was no significant difference in the forced expiratory volume in the first second (FEV1; 0.0 L; 95% CI, −0.1 to 0.1 L), and no change in the rate of episodes of poor asthma control (relative risk [RR], 1.2; 95% CI, 0.9 – 1.5) or asthma-related quality of life (−0.1; 95% CI, −0.3 to 0.1). In addition, children treated with lansoprazole developed more respiratory infections (RR, 1.3; 95% CI, 1.1 – 1.6; P = .02) than those in the placebo group.

A subgroup of children in the study (n = 115) underwent esophageal pH studies before randomization; the prevalence of GER among this group was found to be 43%. In those children with a positive pH study, there was no positive treatment effect with lansoprazole vs placebo for any asthma outcome.

The most common adverse event reported among both groups was asthma exacerbation.

  • This is the exact opposite of what I would expect!

A higher prevalence of upper respiratory tract infections, sore throats, and episodes of bronchitis was noted among patients in the lansoprazole group. The study authors speculate that this may be a result of loss of host defense against bacterial colonization as a result of higher gastric pH levels.

“The results of this clinical trial are uniformly negative regarding the benefit of acid suppression therapy on symptom relief, lung function, airway reactivity, or quality of life,” write the authors. The results also “indicate that PPI therapy for poorly controlled asthma is not warranted.”

In an accompanying editorial, Fernando Martinez, MD, from the Arizona Respiratory Center, University of Arizona, Tucson, notes that although it is not a statistically significant difference, the increase in activity-related bone fractures in the lansoprazole group also raises concerns. This potential complication has prompted an advisory from the US Food and Drug Administration about the risk for fractures in adults receiving chronic PPI therapy.

Overall, however, Dr. Martinez praises the work of Dr. Holbrook and colleagues and concludes that “[g]iven their potential adverse effects, these medications should thus be used with great restraint for treatment of GER/[gastroesophageal reflux disease] during childhood. The substantial increase in use of PPIs in children during the last decade is worrisome and unwarranted.”

Support for this study was provided by the American Lung Association Asthma Clinical Research Centers Infrastructure Award and National Institutes of Health/National Heart, Lung, and Blood Institute grants. Dr. Holbrook and colleagues have disclosed no relevant financial relationships. Dr. Martinez has served as a consultant to MedImmune and has presented at an Abbott-sponsored seminar.

JAMA. 2012;307:373-381, 406-407.

Study Highlights

  • The Study of Acid Reflux in Children With Asthma was a randomized, masked, placebo-controlled, parallel clinical trial comparing lansoprazole vs placebo in children without overt GER but with poor asthma control despite treatment with inhaled corticosteroids.
  • Lung function measures, such as FEV1, asthma-related quality of life, and episodes of poor asthma control, were secondary endpoints.
  • In the subgroup with a positive pH study result, there was no apparent treatment effect for lansoprazole vs placebo for any asthma outcome, including asthma-related quality of life or lung function.
  • Lansoprazole was also ineffective in subgroups defined by markers of asthma severity (either FEV1 at baseline or oral corticosteroid use in the past year).
  • At least 1 serious adverse event occurred in 10 participants in the lansoprazole group and 9 in the placebo group.
  • Asthma exacerbation was the most common serious adverse event in both groups (15 of 25 reports).
  • The investigators concluded that in children with poorly controlled asthma without symptoms of GER who were using inhaled corticosteroids, the addition of lansoprazole did not reduce symptoms or improve lung function but was associated with increased adverse events.
  • The findings do not support routine esophageal pH testing to identify children who respond to PPIs, nor do they support trials of PPIs for poorly controlled asthma.
  • An accompanying editorial notes that the overuse of PPIs in childhood asthma is an example of “therapeutic creep,” or extending the use of a treatment with real or suggestive therapeutic effects in selected patients to other patients in whom the efficacy of that treatment has never been demonstrated.
  • The editorial also notes that therapeutic creep increases the risk for potential adverse effects without any added advantage for patients and may have significantly added to the marked increase in asthma drug costs.

Clinical Implications

  • Findings of a randomized, placebo-controlled trial suggest that PPI treatment of children with poorly controlled asthma but without symptomatic GER is not effective in reducing asthma symptoms or improving lung function.
  • In this randomized, placebo-controlled trial, the addition of lansoprazole was associated with increased adverse events, particularly respiratory tract infections. There may be significant safety concerns for long-term PPI use in children, meriting further research
  • I personally wonder if more aggressive use of Vitamin D replacement would be helpful for the increase in risk of fractures for the patients taking PPI medication.  Yes indeed, further research is warranted. 

Full reference on the dangers of PPI medications

Sleep disordered breathing

25 May 2012 Leave a Comment

by lynnawiensmd in Just For Fun! And you might learn something too!, Sleep Apnea Tags: , , , , , , ,

Often allergy patients have sleep disordered breathing and want to know if allergies contribute.  Most of the time, interruptions in your sleep due to allergy consist of congestion, snoring, sneezing, and possibly apnea.  Anything other than those symptoms should be evaluated for alternative causes.  Specialists dealing with sleep disorders are allergists, ENT (otolaryngologists) and pulmonologists.  There is a board-certification for sleep medicine, so you might want to check for this on listed credentials.  Good night! 

Sweet Dreams!

Sleep disordered breathing  (click to review slides; e-mail me if you need a password) —> lwiens@cox.net

Ouch! my tonsils are hurting me!

16 May 2012 2 Comments

by lynnawiensmd in Just For Fun! And you might learn something too! Tags: , , , , , , ,

All that wheezes isn’t asthma!  Ever heard that before?  A common finding in our clinic is “wheezing” or difficulty breathing not due to asthma, but as a result of large tonsils/adenoids.  A typical history is as follows:

  • Snoring at night
  • He wheezes–(it’s not really wheezing, but loud noises coming from the lungs is often labeled as such)
  • I can never breathe through my nose
  • Examination reveals no wheezing in the chest, but coarse rhonchi transmitted to the chest from the upper airway
  • Look at these tonsils that are almost completely obstructing the back of the throat–

ENT doctors are the surgeons that perform T & A’s as they are popularly called.  (tonsillectomy/adenoidectomy)  The enthusiasm for removing tonsils in young children as a “routine” procedure as decreased because of intraoperative complications, but if it’s needed, the risks outweigh the benefits.  

Interesting patient of the day!

18 Apr 2012 1 Comment

by lynnawiensmd in What's New in Medical Literature? Tags: , ,

What would you think of a teenager seen for a rash, but come to find out he has swelling of hands and lips? Not to mention, other family members have similar problems! This may be hereditary angioedema, Type III. Why is this important? Treatment is available & it’s not steroids or anti-histamines. Check this out—>

Here’s a book on food allergies!

16 Apr 2012 3 Comments

by lynnawiensmd in Allergies, Just For Fun! And you might learn something too! Tags: , , , , ,

The ultimate Family--should be a TV show!

My transcriptionists are not only good at what they do, but when they hear me talk as much as I do, it’s almost family. 

I am reading a book called, Don’t Kill the Birthday Girl by Sandra Beasley, and I thought of you.

  • It’s a memoir about the author’s life with food allergies, what it was like growing up with allergies, etc. She has a variety of food allergies along with environmental allergies. 
  • It’s not very long but it seemed like a book parents who have kids with allergies or individuals suffering from allergies in general would really be able to relate to. Good advice Stephanie!
  • The author is really honest about what it’s like living with allergies but she’s humorous about it at the same time.
  • The one thing that shocked me is that when the author was a teenager she thought about overdosing on Benadryl because she was tired of living with allergies.  Don’t kid yourself, the quality of life in patients with allergy isn’t very good….much worse than heart disease or even diabetes.
  • I think this book could help people with allergies, so they don’t feel alone. I don’t feel alone but I know I’m the only one in my family with allergies and none of them get what an allergic reaction is really like so I’m really enjoying this book.

Stephanie, thanks for the suggestion and I’m sure many of our readers will also enjoy the book. You’ll have to ask her permission to “friend”, but here’s her link—>profile.php?id=1192230038&sk=photos

Here’s the link from Amazon about further information on the book:  Book on Allergies from Amazon

A Penny for your Thoughts!

29 Mar 2012 2 Comments

by lynnawiensmd in Contact Dermatitis & Patch Testing, Nickel allergy, Skin rashes, What's New in Medical Literature? Tags: , , , , , , ,

Nickel allergy

Nickel allergy very common

can result in both cutaneous and systemic manifestations, and can range from mild to severe symptoms. A severe form of this allergy is the Systemic nickel allergy syndrome, clinically characterized by cutaneous manifestations (contact dermatitis, pompholyx, hand dermatitis dyshydrosis, urticaria) with a chronic course and systemic symptoms (headache, asthenia, itching, and gastrointestinal disorders related to histopathological alterations of gastrointestinal mucosa, borderline with celiac disease). This review aims to briefly update the reader on past and current therapies for nickel contact allergy.

Nickel is the main sensitizer; its prevalence varies from 4.0 to 13.1% in different countries and is still increasing. Nickel allergy is more common among women than among men (17% and 3%, respectively). This difference is due to different rates of exposure of skin to this substance; such exposure (from jewelry, leathers, etc) is more frequent among women.  Makes sense, can I go shopping now!

 Nickel allergy has also been noted as prevalent among certain workers, such as hairdressers, domestic cleaners, metalworkers, and caterers, owing to their repeated exposure to this metal. Furthermore, nickel is present in a large number of foods (mainly vegetables), another source of exposure for sensitized patients.

Topical treatment is the first-line therapy for hand contact dermatitis and is also associated with systemic supportive therapies in chronically relapsing patients with severe allergy.  Tacrolimus and pimecrolimus, on the other hand, are antiinflammatory, have immunomodulators that belong to the class of topical calcineurin inhibitors (TCIs), and provide clinicians with steroid-sparing options in the long-term topical treatment of ACD. TCIs are indicated when topical corticosteroids are not indicated or when an anticipated lengthy treatment would lead to inevitable adverse effects.

Here’s a treatment doctors often forget about—>Phototherapy is very effective in the treatment of hand eczema; narrowband ultraviolet B (UVB) Phototherapy booththerapy has demonstrated clinical efficacy also in therapy for psoriasis and atopic dermatitis.

The safety and efficacy of this therapy in cases of hand eczema was evaluated in a randomized controlled prospective study of 15 patients who had no response to conventional topical therapy. The patients were treated three times weekly for 9 weeks with narrowband UVB on one hand and with topical photochemotherapy using 0.1% 8-methoxypsoralen gel on the other hand. Patients were assessed once each week during the treatment period and were evaluated 10 weeks after the last treatment. All of the 12 subjects who completed the trial improved, showing a statistical difference between modalities. Both broadband and narrowband UVB appear to be as effective as topical psoralen plus ultraviolet A (PUVA) therapy in the treatment of chronic hand dermatitis. However, the risks of phototoxicity and dyspigmentation associated with local PUVA therapy make UVB therapy a preferable initial therapeutic option.

Systemic immunosuppressive therapy may be considered for those cases of hand eczema that are refractory to topical steroids and phototherapy. If ACD involves an extensive area of the skin (> 20%), systemic steroid therapy is required. In general, oral prednisone should be tapered over 2 or 3 weeks because rapid discontinuation can cause rebound dermatitis. Similarly, the usefulness of cyclosporine for this condition seems limited to the short term.  Although one study demonstrated prolonged disease remission in 74% of patients 1 year after a 6-week course of cyclosporine (3 mg/kg/d), other studies have shown high relapse rates within weeks of drug discontinuation.  Cyclosporine is probably not worth the risk. 

Nickel, as other allergens, may interact with essential divalent ions with similar chemical properties at ionic sites of important biomolecules. Based on animal studies, some effects of nickel may be eliminated or reduced by supplementing with divalent essential metals. Weissmann and Menné reported cases of nickel dermatitis as having improved following oral administration of zinc sulfate (ZnSO4).   One clinical study showed that the administration of ZnSO4 could improve the clinical manifestations of nickel contact dermatitis and could eliminate or reduce the majority of patch-test reactions; intolerance to ZnSO4 was not observed. The study showed that ZnSO4 therapy is efficacious and safe.

Low-nickel Diet

Patients with diffuse manifestations can reduce clinical cutaneous and gastrointestinal symptoms by following a diet with a low nickel content. Nickel frequently contaminates food, and avoiding it is very difficult. The daily intake of this metal with food is about 300 mg, mainly from oatmeal, nuts, cocoa, chocolate, and soybeans. In sensitized patients, nickel ingestion could cause a recurrence of chronic contact dermatitis but could also cause flare-ups of other dermopathies such as those triggered by immunoglobulin E (IgE)–mediated allergy (mainly urticaria). This evidence suggests that nickel allergy may be not only mediated by type I and type IV Gell and Coombs reactions.

The normal daily dietary intake of nickel ranges from 0.02 to 0.48 mg. Many studies have demonstrated the relationship between nickel ingestion and dermatitis flareups.  In 2006, Jensen and colleagues reported the results of a meta-analysis of these studies performed to determine the median values of nickel that could elicit allergic reactions. It has been demonstrated that nickel sulfate may provoke chronic eczema when orally administered in the range of 0.6 to 5.6 mg daily as a single dose, and there is much evidence of this relationship (eg, flareup of eczema upon dietary oral nickel challenge, improvement of eczema after starting a low-nickel diet, and management with oral disulfiram or hyposensitization therapy with low-nickel doses).

This by the way, isn’t traditional wisdom to treat a skin allergy (nickel) with dietary manipulations such as low nickel diet. 

Disulfiram (Antabuse, Wyeth-Ayerst, Philadelphia, PA) is a nonconventional pharmacologic agent used in therapy for nickel contact dermatitis. It is a chelating agent for metals such as nickel and cobalt, but its main use is as supportive therapy for alcohol addiction.

The concept of immunomodulation, developed in the 1990s, is as follows: the induction of tolerance to a specific antigen may be obtained by a mechanism of active suppression or by the induction of a clonal allergy. The experiments of Bagot and colleagues, carried out in a double-blind-versus-placebo study, clearly demonstrated that oral nickel administration in humans may importantly reduce the number of circulating T-cell lymphocytes activated against this antigen.  In 1992, Van Hoogstraten and colleagues demonstrated that complete tolerance can be maintained for 2 years as long as oral contact with the allergen is avoided. Oral administration of nickel could induce an immune-specific tolerance by a clonal expansion of subtypes of CD4+ T-cell clones, T-regulatory cells, with suppressing activity that limits tissue damage and inflammatory-response T-regulator cells.

In 2009, the authors performed a clinical trial of oral hyposensitization therapy with low doses of nickel in 67 patients affected by systemic allergy to this sensitizer. All patients reported a significant benefit in regard to both cutaneous and systemic symptoms, with the reduction or absence of itching and partial or complete clearing of ACD after the first 4 weeks of treatment. In fact, 70% of the patients completed the increasing phase (10 weeks) and the maintaining phase with the following results after the reintroduction of a nickel-free diet: 67% reported a complete remission of symptoms; in 23%, a clinical improvement was noted, with the rare appearance of cutaneous or digestive symptoms of lower intensity; and three patients also reported a reduction in weight. Adverse reactions were observed only in 18 patients: 12 patients with primary cutaneous dermatitis reported mild itching, and 6 patients with gastrointestinal manifestations reported digestive disorders of low intensity.

This systemic therapy led to favorable results both in regard to cutaneous symptoms and in regard to gastrointestinal histologic modifications induced by nickel allergy, in contrast to all other therapies that could only act on the dermatitis.

I didn’t know there was any therapy for nickel allergy except to avoid…the more you know the less you know.  For the full article, click here:  (let me know if you need the password)

New advances in nickel allergy

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