>> if we could get -- come backtogether, we'll finish our case studies. so lots of good discussion during the break, and some of the stuff we're goingto cover as we go along here. so let's start with case number 2. this is a patient that's 66 yearsold, and on march 2nd they go to the or for an exploratory lab. and they insert a foley, and the patientis transferred to the icu postop. on the 3rd, the patient isstable, and the foley is in place. and on the 5th, they still have their foley.
the patient febrile on this day andcomplaining of pain in the right lower back. the wbcs are increased to 19,000. he has cloudy, foul-smelling urine,and the urinalysis shows 2+ protein and nitrite and 2+ leukocyte esterase. wbcs are 15 millimeters cubedof unspun urine and 3+ bacteria. culture was positive for greaterthan 10,000 colonies of e. coli. so this is a voting question. is this a cauti, and if so .what type? so your choice is no uti, or that thisis a uti that's not catheter associated,
or it is catheter associated, and it's suti2a, or that it's a catheter associated abuti. okay. let's see what you say, 97 percent say that this is a suti 2a, andit's catheter associated. and you are correct. you guys got that pretty well. so let's look at the rationale for this. in this case, the uti criteria were notin the poa time period, the first 2 days. it's catheter associated because the date ofevent is 3/5, which was foley day number 4. okay? and i do want to clarify, actuallythis is one of the questions that came up.
in this case, they documented rightor lower, left lower back pain. i'm sorry. they documented right. did they document right? either right or left lower back pain would bepretty synonymous with flank pain or cva pain. so you -- we do allow you to use that. however, if you just have lower back pain, wecan't really say that that's specific enough to say that this is cva pain becauseyou know it could be from laying in bed. it could be -- you know it's not -- we needmore details that it's in this flank area.
so similarly, sometimes we getquestions about abdominal tenderness. can you use abdominal tendernessto meet the suprapubic tenderness? and the answer would be no. it's pretty general terminology. if they said bladder tenderness,that would be acceptable. so okay. and they had the urineculture was the lower colony count. but they had positive dipstickany pyuria to meet the criteria. okay. case 3 is a 58 year oldpatient that's admitted to the ed with a gi bleed, and they insert a foley.
on the second day, the patientspiked a temp of 38.6. and the indwelling catheter remains inplace, and a urine specimen is sent. culture results are greater -- are100,000 pseudomonas aeruginosa. on day 3 -- that was collected on day 2 -- they're afebrile on this day andasymptomatic, and antibiotics are started. day 4 and day 5, the patientis asymptomatic and afebrile. so is this an hai? and if so, what type? this is a healthcare associated uti, but not acauti because the catheter had not been in place
for greater than 2 calendar days. or, no, it's a uti that is present on admission. or it's a cauti suti criterion 1a. okay. let's see what you say. the answer is 2. it's a uti that is poa, and, oh, weget 70 percent were -- said that. almost 20 percent, however, saidit was a cauti suti criterion 1a. so let's look at this. patients meets suti 1a criteriaon day 2 of hospitalization.
so they had a temp, and they hada positive urine culture on day 2. that is within the poa time period. curious, does anybody that gotthat wrong unclear on that? so again, determine if the poa criteria are met. if they are met -- if they are notmet, then you set aside all those days. this is the way i think about there. if they don't meet poa criteria,set aside those first 2 days. don't even look at them anymore and consider it. just look at the days after that.
any symptoms that were only present duringthose first two days are not going to be able to be utilized to meet the hai definition. if they're still present, if they're presentin the first 2 days, and when you're looking at 3 days -- day 3 and on,if they're still present, they can be used to meet the hai criteria. so if that helps you, thathelps me when i think about it. i determine if it's poa. if it's not poa, i stop looking. i don't even care what happenedin the first 2 days.
okay. it's my funny email. janet [assumed spelling] stole my joke. this is an email that we got fromsomebody on the subject ssi reporting. this is a user email. could you help me with the definition ofsome examples of stab wound infection? does a stab mean laparoscopic, or likea street fight and an ice pick is used? i thought -- you know and then i google-- i look for clip art on ice pick. i thought i'm not going to be ableto find a picture of an ice pick. who uses an ice pick anymore.
right? i found one. so, all right. case 3, continuing case 3, on the 16thday, the foley's remained in place. the patient completed treatment for the uti. that was on hospital day -- and they completedon -- that treatment on hospital day 11. they did develop a dvt. they have been afebrile tilltoday, but the temp has be edging up the last 2 days and is not 38.1. and they have a yellow productivecough and bronchi present.
the urine is cloudy the next day. the fever is 37.9. they continue to have the cough. they collect urine and sputum cultures. the next day, both urine and sputumcultures are positive for staph aureus with greater than 100,000 in the urine. so now we're going to ask this question about isthis an extension, or is this a new infection? so do they have a cauti? yes, the first uti was resolved,and the treatment was finished.
no, it's an extension of the first uti. or no, the uti is secondaryto a respiratory infection. you can vote. okay. let's see how you did,84 percent of you said that this is the first one wasresolved, and the treatment was finished. so this is a uti -- new uti,and that is the correct answer. they completed their treatment. the symptoms had resolved, and only tobe followed by onset of new symptoms. and criteria are met, so it's a cauti.
and i do want to say that sometimespeople think that like clabsi, you can say that a cauti is secondary to anothersite of infection, and that is not the case. and i just -- you can't -- there's nosecondary utis for reporting purposes. and our favorite rule of all thatthe fever cannot be attributed to another source of infection. this information is, if any of youare interested in looking at it, in as far back as the march 2012 newsletter. and there's also if you lookat the criteria you'll note that there's no asterisk following the fever,and i think i highlighted that earlier.
another email. i have my clip icu data from may. is it possible to fax or mail you the data? i am a one-person department, and with h1n1going on, it would be much easier for me, as opposed to fitting it into a format. no. wouldn't that be nice? all right. case number 4, a 76 year old womanis admitted from an ltac at 8:00 a.m. for surgical debridement of the sacral decub.
medical history is notable forsevere rheumatoid arthritis. she has congestive heartfailure and atrial fibrillation. a routine admission ua performs positivefor leukocyte esterase and 3 wbcs by high-power field of spun urine. patient is afebrile, denies anyurgency, frequency, or pain. no suprapubic or cva pain included. the foley catheter was present on admission,and a peripheral iv is inserted in the or. she is admitted postoperativelyto the telemetry unit. the next day the wound care specialistdocuments that the wound is clean.
a temperature is 37.4. the foley is draining cloudy urine. the next day, she is transferredto a surgical unit. they must not have had roomfor her, or i guess she just -- she got stable enough to betransferred out of telemetry. a temp of 37.9, the foley is removed, andshe's encouraged to push her po fluids. and they send a urine culturefor lab for sensitivity also. on the 8th, the patient complainsof dysuria and pain with palpation to the suprapubic area, and they start bactrim.
her urine specimen sent on 4/7, results arepositive for e. coli greater than 100,000. and the patient is afebrile, and she'spreparing for discharge back to the ltac. so voting question, does the patienthave a uti, and is it a cauti? so you say no, it was present on admission. yes, the patient has a suti 1a,and it is catheter associated. or yes, the patient has a suti 1b, butit is not a catheter associated uti. okay. so let's see how you did. and we have a split decision here, 70percent, almost the same amount as last time when they were split, 70 percent thought
that this patient has a suti1a that is catheter associated. and that is the correct answer. so let's look at why. criteria were not met in the poa time period. so if we go back, patient came in on 4/5and met criteria on it looks like 4/8. is that right? yes, when they had dysuria and painafter the catheter was taken out. this is therefore a cauti. they met the criteria for the uti onthe day after the catheter was removed,
and the catheter had been inplace for greater than 2 days. so do just note that you know uas might bepositive for many noninfectious reasons, especially somebody that'scoming into a facility with a foley that's been in for a long time. they probably will have a positive ua. that catheter itself can causeyou know the formation of wbcs. so don't take that as in and ofitself the patient has a uti. okay. which location would the cauti beattributed, telemetry or surgical unit? oh, it doesn't look like the voting isworking on this one for some reason.
sorry. so we'll just go ahead and answer it. it's going to be attributedto the telemetry unit. the date of event is 4/8, which is the dayafter transfer from the telemetry unit. okay. case 5, on may 15th, we have a 48 year oldmale that's involved in a motorcycle accident with a closed head injury, multiplefractures, taken to the or for open reduction and internal fixations andevacuation of a subdural hematoma. foley catheter and left subclavian catheterplaced in the -- had been placed in the ed. patient remains on the ventilator thatwas placed in the or postoperative -- remains on it postoperatively, andthe lungs are clear bilaterally.
on -- 6 days later on may21st, temp max is 99.8. lungs are still clear. foley is still in place anddraining clear yellow urine. patient is still on a ventilator. sputum production is slightly increased. on may 22nd, the patient hasa temp of 100.4 fahrenheit. vent settings are stable. there's no change in the sputum. may 23rd, temp remains the same.
wbcs are 14,000, and the lung soundsare clear, and the chest x-ray is clear. patient is still on the vent. the foley and the centralline are still in place, and the pan culture the patientbecause of the wbcs. empiric antibiotic treatment has -- is begun. on may 24th, the urine culture is greaterthan 100,000 of pseudomonas aeruginosa, and the blood culture's alsopositive for the same organism. physical assessment is normal. there is no patient response to suprapubicor costovertebral angle palpation.
so does this patient havea uti, and if so what type? and it looks like the votingis working on this one. no uti, an abuti, a suti 2a, or a suti 1a? okay. let's see what you have to say. oh, a split here, 60 percent say it's anabuti, and 31 percent say it's a suti 1a. that's interesting. so the actual correct answer is it's an abuti. the patient didn't have any uticriteria symptom in the presence, and there was a positive bloodculture matching the urine culture.
that made this an abuti. note that the fever has tobe greater than 100.4. tricky, huh? to meet the fever requirements fornhsn definitions, and this was 100.4. is the catheter associated abutireportable if the cauti reporting is in plan for the patient's location? so are abuti -- catheterassociated abutis reportable? and this is not voting. so you can just yell out.
yes. absolutely. they have to be reported if you have in plan cauti surveillance markedon your monthly reporting plan. some facilities think they just have toreport sutis, but that's not the case. okay. you ready for another? are these funny to you? because they're funny to me. [inaudible]. sometimes we don't answer them.
usually we don't answer them. so this one is -- this was just -- i thoughtthis was funny the way they wrote this. the cardiothoracic surgeon also noted that the patient's prognosis was quitepoor unless dramatically improved. okay. thank you, captain obvious. case number 6, on 8/25 wehave a 73 year old patient in the neurosurgical icu that's admittedfollowing a cerebral vascular accident. he's ventilated. he has a subclavian catheter and afoley catheter inserted on admit.
and he's reacting only to painful stimuli. on 9/2, so what is that, 8 days, 7,8 days later, the patient has w -- the white cells are slightly elevated at 12,000. temp is 37.4 celsius. the urine is cloudy. the lungs are clear to auscultation. they're still ventilated and still catheterized. the next day, wbcs go up to 15.8. temperature max is 37.6,and they are not febrile.
breath sounds are slightly coarse. they have some minimal clear sputum. the urine is unchanged. they do a ua, and they also sendendotracheal and urine specimens for culture. there is no suprapubic or cva pain noted. on 9/4, the urinalysis ispositive for leukocyte esterase. the nitrates and the wbcsare too numerous to count, and the blood in the endotrachealculture's no growth. the urine, however, is positivefor 100,000 of e. faecium.
so does this patient have a uti? and it looks like the voting is working. if so, what type? you can say they have an abuti, theyhave a suti 1a, a suti 1b, or no uti. okay. let's see what you think, 72 percent of you say there is no uti. there's no urinary symptoms. there's no fever greater than 38 celsius. there's no matching bloodculture to the urine culture.
so there's no uti by surveillance criteria. very good. so like i said, surveillance definitions workbetter in some patient populations than others. you know we do want to makesure that even our patients that are ventilated are gettingthorough assessments to look for the uti symptoms other than fever. sometimes some facilities have had to havedialogue or education with the clinicians. and you know i'm not going tobeat a dead horse and tell you that surveillance definitionshave to be followed.
okay. grandpa unlucky, on march 1st, grandpa unlucky has now been inyour medical ward for 4 days. he had his foley catheter,which was placed on day 1. it was removed today. he's found to be severely anemic andis transfused with 2 units of blood. grandpa has been having trouble voidingthe next day on march 2nd and has not felt that he's been emptying his bladder. he's catheterized post void and 600milliliters of residual urine is collected, and the foley catheter is left in place.
on march 3rd, he complains oftenderness upon suprapubic palpation. his urine is sent for culture and is reportedas positive for 100,000 of e. faecium. does grandpa unlucky have a cauti? you can say yes, a suti 1a; yes, a suti 2a;or no, his uti is not catheter associated because the new catheter hasonly been in place 1 day. okay. let's see how you answered, 82 percentsaid that this is a suti criterion 1a. good job. so why? he didn't have a poa uti. it wasn't in the first 2 days.
foley was in place for 4 days onmarch 1st when it was removed. then it was replaced on march 2nd, the next day. so this is now foley day 5 since there wasnot a full calendar day without the foley. he meets suti criterion 1a with the suprapubictenderness and a positive urine culture of greater than 100,000 offoley day 6, march 3rd. okay. very good. case 8 is our last case, and then i'm goingto give you guys a little bit of information about what the cauti review group has been doing because i know you're allinterested in that information.
so case 8 a 59 year old femalethat's admitted with uterine cancer and has a foley inserted on admit. she has a total abdominalhysterectomy performed the next day, and on the 18th she's progressing welluntil she has a fever spike of 101.3. a blood specimen is sent,and results are no growth. i'm assuming that her foley is still in here. i don't say that, but we'll say that it is. on the 19th, she's asymptomatic. on the 20th, she's asymptomatic.
on the 21st, they send another-- a urine specimen. maybe her wbcs are elevated, and theresult is 10 to the 5th of e. coli. she's then asymptomatic on the 22nd and the23rd, and the took out her catheter on the 23rd. does she have a uti, and if so what type? she has an abuti. she has a suti 1a or a suti 2a. or she has no uti. okay. you guys voted quick on thisone, 94 percent said she has no uti. and you are right.
good job. there's more than one gapday between the date of the fever and the date of the urine culture. so let me get my pointer to work here. fever, asymptomatic, urine cultures, sothere's more than a single gap day here. and then you know if she had a fever onthis day, she would have met criteria here. but she is asymptomatic here,and she's asymptomatic here. so you have to look. you can't just stop lookingat this urine culture.
you know there's a fever here,and then you get a urine culture, and you say oh, she doesn't meet it. then you have to look. does she meet it here or hereas well with the urine culture? so that's why i included those last 2 days. that sometimes -- sometimes patientsor users send us the information, and they don't provide that information. it makes us worry that they'reforgetting to look past that culture. i have gotten a couple questionsabout the order of elements.
can they have the culturefirst and a fever later? the answer is yes. maybe they're collecting the urineculture because of elevated wbcs, and they just haven't started their fever yet. there's no specific orderthat they have to occur in. okay. so you guys did a great job. and i do want to give you some informationabout the definitional update for cauti to tell you where we are on that. as i said, we started the work in 2012.
the definition was last updated in 2009. user concerns, boy these are a surprise. we haven't heard these today. have we? clinical correlation, you knowconcerns about the fact that it doesn't seem to be -- have good clinical correlation. as i said you know we've heard about lackof sensitivity in specific populations. i was telling somebody during the break. you know their concerns were that they were -- we were overcalling, but wealso hear from other people
that they believe that they'rebeing under-called. and some people that are looking at thesepretty systematically are telling us they are. there is some lack ofspecificity related to you know this issue of a fever being due to more than onecause, and specific candidate organisms that are pathogens, specifically candida. you know what does -- what is the trueclinical meaning of candida in the urine? you know we've had our group that wepulled together included a lot very -- you know the top experts in cauti surveillance. you know dr. sanjay singh was involved.
dr. fakih, mohamad fakih from the university ofmichigan, very published, acknowledged people, and honestly there was a discussion and a debateabout whether or not candida should be removed. it wasn't across the board to believe thatyou know we should stop collecting those. and there has not yet beena decision about that. but it is something that is being considered. and the other issue, other organism that we hearyou know some questions about is staph aureus. you know medical physicians are trained thatif a patient has staph aureus in the blood or in the urine that you should look tothe bloodstream infection to make sure that that's not being seededmore often from the blood
to the urine in that -- with that organism. and as you know, staph aureus iscurrently included in their definition. so that is a concern thatwe have heard from users. so this work has taken place withteleconferences with subject matter experts. somebody -- i know that lauren [assumedspelling] is here in the audience and possibly a couple of other people thatwere included on these teleconferences. they were a couple of times a week. we were meeting a couple times a week early on. and it included ips.
it included epidemiologists. it included state health departmentindividuals, microbiologists. a big part was a microbiologist input on this. and we did an evidence review of what isout there to better inform our decisions. also we collaborated with apic to discuss -- to survey facilities about their laboratoryculture practices, especially around candida. did any of you participate in that? very few, wow, surprising. that's unfortunate.
we have the data collected. it's being analyzed right now. let's hope. the target date is to have itfinished analyzed this month. and then we're hoping that the results of thatwill help us to create a definition that is -- can be consistently applied by all facilities. we've gotten a lot of feedback from facilitiesthat their culture results are not reported out you know so that they can meet,for instance, suti criterion 2a. they don't get those culture results thatare less than 10 to the 4th or 10 to the --
you know they don't get all this. or their wbcs in the urinalysis arereported differently than our ranges are. so we are trying to get --we're collecting information about how the labs are reporting thoseand utilizing that because we want to make it whatever we end up with thedefinition being, we want it to be as fair as possible for all of the facilities. we also had one of our eis officers who wentand provided an epi aide with a facility that had a very high sir for cauti. and it addition to doing the epi aide andhelping them identify prevention efforts,
she was able to collect a lot ofinformation that's going to be very useful to us as we look at the definitions. interestingly enough, one of the thingsthat she found, which was kind of puzzling, was that the -- there were a lot of patients that were end-stage renalpatients that had foley catheters. and that seemed kind of odd and problematic. and they were often sending urinecultures from these patients. and the term that i heard, i had never heardit before, was well, that's bladder sweat. that's not urine.
these people don't make urine. that's bladder sweat, and weshouldn't be culturing it. so you know there's some interesting thingsthat i think are going to come out of that epi aide, the analysis of that. and that facility has actuallyalready started to make some changes, and they have brought theirrates down quite a bit. some of the changes that they looked atwere using a reflex ua to decide whether or not to send out urine cultures. so they've really backed off on the numberof urine cultures that they're sending.
and i think that was -- i know therewas another change that they made, and i can't think of it off the top of my head. but that was one of the biggerones that they've instituted. and we're also collaboratingwith the cusp cauti group. how many here are involved in cusp cauti? a lot more of you, okay. we're getting great data from thatgroup and using their findings from that to better inform the decisionsthat we're making, as far as how to update the cauti definition.
so we're anticipating a 2-step process. a short-term update for 2015, and wewant to address the issues in 2015 that will even the playing field,that will bring the clinical and surveillance determinations closer tothe extent that we can do that together. and again we have to make sure that thesechanges are still feasible for collection for you guys because i know nobody is sittingaround out there twiddling their thumbs and is asking for more datapieces to be collected. so we have to make sure that anything we includein it is something that's easily accessible by everybody and is not overly burdensome.
the long-term goal is that we're going to havean electronically collectible cauti definition. okay? but that may be 5 yearsdown the line or wherever. it's the long-term plan. now -- right now we're -- just for 2015,we're trying to get this an improvement in the definition, so that you know it's alittle more fair and it's a little more relevant to what you're doing and how you're using it. i hope to have more information at apic 2014. so if any of you are coming there, youknow come and hear what we have to say. i included this slide you know just forthose of you that are struggling with this,
things that you might think about doing. and i can't say that theseare hard recommendations. i can only tell you that these are some things that some facilities havefound that have helped. as i said, reflex urine cultures,sending the ua along with the culture and only perform the cultureif the ua is positive. have maybe discussions with your physicians about how they're culturing,why they're culturing. are they culturing too much?
changing long-dwelling catheters beforecollecting the urine to exclude colonization. obviously if the patient's had a catheter infor 2 weeks, and you call a culture from it -- pull a culture from it, it'sprobably going to be positive. so let's not try to do that, althoughi'm going to say that i was talking to someone here that has been doing this. and she's interestingly said that she thinksthat she's starting to see maybe her rates creep up because she's not sure thatpeople are using good technique when they put the catheter back in. so and you know in additionto the prevention efforts,
strengthening the diagnostic practiceswill help to improve the cauti rates. you know if we don't collectunnecessary urine cultures, you don't have a urine culture,you don't have a uti. so we want to get rid of the unnecessary ones. that will also increase the patient's safetybecause we won't have all those adverse events that go along with unnecessary treatment. and really important, it's going to increaseyour staff morale because i hear you guys saying and we all hear you saying, you knowour people, we are dedicated to this. we are trying to lower our rates.
and it's very hard on staff morale whenwe have to identify these things as cauti, and we don't clinically believe they are cauti. so we do hear you. these are some things that youmay be able to do to help that. we're working on the things that we areable to do to try to help that also. and i hope that you -- i hope you hearthat from me because it is very true. okay. the last funny email, andthen we'll have time for questions. i thought you would enjoy this one. i think they meant to hitforward, but they hit reply.
dear -- and this is what we sent out. dear nhsn safety component users. in january 2010, nhsn will be changing thespecimen source closed list that's used for lab id event reporting. the change is being blah,blah, blah, blah, blah. so that's what we sent out. we sent it as a blast emailto everybody that does lab id. and this was the response that we got. sue, what is all this about?
i'm sick of nhsn already,and we haven't even started! so we didn't respond. so with that, i will open it up for questions. can you flick -- is there a -- no,there should be a button there. yeah. >> can you hear me now? >> yes. >> all right. this is more just a comment.
i'm you know looking at thesubtleties within these definitions. >> uh-huh. >> i think that when we have the vaecalculator, we have a lab id calculator. i think a cauti calculator should be next on thedata gnomes' wish list because i think it would in fact streamline a lot ofthese questions and concerns when you have this you knowskip a day, add a day. >> absolutely. and we're talking about that. i think we want to get thedefinition fixed, and then do it.
>> i realize you want tohave it tied down first. >> but, yeah. absolutely. yep. >> yeah. you want to have ittied down before you do that. but i think that would be a great thing to you. >> yep. >> thank you. >> we agree.
yes? >> i have a question about the transferrule for the patients who are on -- who are transferred twice in one calendar day. >> just on the rationale on that, on wednesdayyou said that the rationale is you attribute it to the unit that they had the most exposureon, and then today you said you attribute it to the unit that they were at first,the first unit before transfer. >> okay. i don't think i said -- >> am i not -- >> that he had the most exposure.
if i did, that was a mistake. >> that's what i heard. >> but i shouldn't have said that. >> i just wanted to make surei didn't heard it incorrectly. >> no. i think the rationalethat we used is just that it's the farthest one backduring the transfer time period. and so we're figuring that'sgot the longest exposure. you know we don't want to attribute tothe first -- the most recent transfer. so we're going to go back to the latest one.
>> and that makes complete sense. i just wanted to make sure i understood. >> so i'm sorry if i said that. i was incorrect if i did. >> yeah. anybody else? okay. well, we're going to finish early. but janet has an announcementthat she wants to make. thank you very much this morning for all of you. appreciate it.
>> okay. so i wanted to get this on the record. since so many of you aredoing hpros and kpros, i -- at the end of the presentation,someone said, wait. was that supposed to be an and betweenthe c-reactive protein and the sr? and i then had a moment of oh, mygosh, i think these were all ors. and i went back, and the actual-- the physician i worked with and who worked with the msis was here. and he goes, yes, you were correct, janet. you -- it should have been an or.
so i'm like great. i messed up the 100, should have been 10. and it was supposed to be an or. so then this morning of course youknow i'm losing sleep over this. and i emailed him very first thing and said, did i really mess up 2 thingsin our new pji definition? so i sent it to dr. fagan [assumed spelling]. he's wonderful to work with. and he goes, janet, nothingis wrong in this definition.
i apologize. i should not have told you it was an or. it is supposed to be an and. so that is correct. it is supposed to be and in criterionb. your c-reactive protein and, and then the greater than 100 is correct. we had when we first wrote thiswe worked on this for a while. we had had it at greater than 10. and then when the msis met again a final time,we realized the c-reactive protein greater
than 10 definition is reallypointing at chronic knee infections. the acute definition for an acute knee infectionis a c-reactive protein of greater than 100. so everything's fine in your pji definition. and we apologize for any confusion about that. and i will as well put thatinto our nhsn newsletter, that the current pji definition is correct. it's the and. it was only kind of mentioned here. but that greater than 100 is correct becausethat's evidence of an acute knee infection.
okay. i hope that that helps clarify that.
0 komentar:
Posting Komentar