I am sitting here on Father’s Day and reminiscing about my father. He was born in 1919 into a struggling first-generation immigrant family in Chicago. Over the years he worked hard, as folks who lived through the Great Depression and World War II did in those days, and became a successful businessman. He taught me many things, but above all the importance of interpersonal relationships and the value, the imperative, of always treating everyone with respect and dignity—from your bosses to the housekeepers. This value serves me well, as it did him. He died in 1998 after a short but terrible battle with pancreatic cancer. My mother, to whom he had been married for 54 years, was devastated but eventually bounced back. She is now 86 and in an independent-living apartment—incredibly, totally cognitively intact, but with multiple medical issues, some of which I have previously mentioned in my blogs.

The recent Time Magazine article by Joe Klein, “The Long Goodbye,” (1)got me thinking about the issue of how we as a society approach the impending deaths of loved ones. Klein points out how lucky he and his parents were to get into the Geisinger system, where patient-centric, integrated and holistic care was provided and his parents were cared for, as he would like to be. He states, “Doctors are trained to do whatever they can to save a patient, even an elderly one, and that is an excellent thing. But that Hippocratic impulse has been subtly undermined by the rewards of fee-for-service medicine and by the threat of malpractice suits, which militate in favor of ordering the extra MRI or blood test or dialysis even for a patient who probably has only weeks to live.…” A few days later Austin Considine, writing in The New York Times, noted that Klein was only one of many who have recently written on this topic, with articles in New York magazine and The Atlantic Monthly in the past year articulating the same themes (2). The managing editor of Time, Richard Stengel, notes, “[this is] an issue that’s always on people’s minds…every day there are thousands and thousands of people making these agonizing life-and-death decisions.”

These musings by noted popular writers were brought into focus for me, not because of the frailty of my mother’s medical condition, but by an outstanding article in the recent American Journal of Kidney Disease by Jane Schell and colleagues: Discussions of the Kidney Disease Trajectory by Elderly Patients and Nephrologists: A Qualitative Study (3). The purpose of the article was to better understand with whom nephrologists and elderly patients interact and discuss the future at various stages of kidney disease. The results are fascinating and worth summarizing.

Schell developed a process map of the progress of kidney disease, from diagnosis to disease progression to treatment preparation to dialysis to end of life. She then was able to identify, through questionnaires and interviews, themes for patients and nephrologists at each of these steps. For patients, Schell’s process map indicated diagnosis leads to shock, and then, as treatment preparation begins, patients are quite uncertain about how the disease will progress. As dialysis and further clinical deterioration occur, patients express a lack of readiness for living with dialysis and facing death. For nephrologists, Schell noted there is a real struggle initially to explain how complex kidney disease is, and a real feeling of frustration with the lack of control over the progression of the disease. As dialysis is initiated and clinical deterioration occurs, nephrologists tend to avoid discussions of the future. So what is missing here? We have a failure to communicate! As Schell concludes, “This study shows key areas within nephrologist-patient communication amenable to interventions that address patient understanding and treatment decision making. Effective communication has been shown to enhance patient understanding, shared decision making, and implementation of care plans consistent with patient preferences and goals.… These data show the gaps that exist in how nephrologists and elderly patients discuss and understand the kidney disease course. Interventions that focus on addressing emotion, uncertainty, and understanding may improve patients’ experiences. Effective communication may enhance patient-centered care and promote greater shared decision making.”

It is no coincidence that the recent RPA Clinical Practice Guideline is titled “Shared Decision Making in the Appropriate Initiation of and Withdrawal from Dialysis.” In order to share, one must communicate. Seeing frail, elderly patients in the office quarterly or the dialysis facility only once monthly is insufficient to permit the relationship-building, the establishment of trust, that is essential for true, deep discussions of these personal but critical issues.

Francis Weld Peabody was a distinguished clinician and teacher, educated at Harvard and Johns Hopkins in the early 20th century. His words first published in JAMA nearly a century ago still ring true:

“The good physician knows his patients through and through, and his knowledge is bought dearly. Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine.… One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”

Striving to bring quality to life,

Allen R. Nissenson, MD
Follow me on Twitter

To make sure you receive a notification when a new blog is posted, click here

To comment on this post click here

1. Klein J. Time Magazine, June 11, 2012.
2. Considine A. The New York Times, June 13, 2012.
3. Schell J.O., et al. AJKD 59:495, 2012.

My wife is a maniacal exerciser. Three days a week at the gym, weights and cardio; two days a week, Pilates; Saturday, walk on the beach with a girlfriend; Sunday, walk on the beach with me. Although she comes from a family of women with osteoporosis, she has incredible bone density.

Two weeks ago, we were in Santa Barbara visiting our niece, her husband — a postdoc at University of California–Santa Barbara — and their beautiful five-month old daughter. After a wonderful visit, we took off for a relaxing lunch and stroll in Carpenteria, a few miles south of Santa Barbara on the way home to Los Angeles. We were walking around the main drag when my wife turned to point to a cute shop, tripped, and hit the ground. Her foot immediately began to swell, so we got some ice for the one-hour drive home.

Over the weekend, we treated the foot with ice, heat and liberal painkillers, but by Sunday night we knew that we would need to see an orthopedist for an examination and x-rays. That is when it began to get really painful.

On Monday morning, I contacted the chief of orthopedics at a nearby hospital who had his assistant squeeze my wife in to see someone at noon that day. The administrative assistant who made the arrangements couldn’t have been nicer, and we felt like we were on our way to a resolution. We drove to the new state-of-the-art facility. It was a blustery day, and we had been told that we should drive up to valet parking so we could get a wheelchair to take my wife to the appointment. When we pulled up, the valet said, “Sorry, the garage is full.” I insisted that I needed to help my wife to the appointment; after consulting his colleagues, the valet came back with a ticket and took the car.

We walked to the bank of patient elevators, about a block inside the building, rode to the second floor and arrived to find out they had no record of the appointment. I called the administrative assistant who had made the arrangements, and she got that straightened out: “computer malfunction.” Next was the foot x-ray, with the patient having to navigate two large, heavy doors while holding a “patient notification pager” to get from the waiting room to x-ray. We saw a senior orthopedist, who diagnosed a Lisfranc fracture after the examination and review of the films. He thought an MRI should be done to better see the tendons and determine if a cast or surgery would be best. He wrote the order but said we would get a call in a day or two after the authorization was obtained.

By Wednesday, we hadn’t heard from the office and called — we were told they had the request but only one person in the office was authorized to interact with insurance companies, and she was out. Needless to say, after two additional days of pain and essentially no treatment, my wife was outraged. The office said they would see what they could do and would call us back. We called again on Thursday, and they said that the “insurance person” was still out; the one on the phone said it was not her job, but she would see if she could help and would return our call. When we called Friday morning, after not hearing from anyone on Thursday, we were agitated but glad to hear that the MRI had been authorized. We were instructed to call radiology for an appointment.

When we called, radiology said the earliest appointment was for the following Monday. We were incensed — a painful, though admittedly not life-threatening injury, and another several days before the needed test so that the correct treatment could be started. I again called the chief of orthopedics, and the administrative assistant called back in five minutes to say we could get the MRI at noon that day.

We were grateful, and my wife had a friend take her to the test. After it was completed, she asked the technician to please have the radiologist call the orthopedist with the results as soon as they were ready. He stated that the test was not marked “stat” and would be read the following Monday. When my wife went up to the desk to ask the radiology administrative assistant how to get this expedited, the assistant was sitting at the desk, eating lunch, and said, “There is nothing that can be done. It’s not marked stat, and only the ordering doctor can change that.” A final call to the chief of orthopedics, the MRI was read, and it showed not one but two fractures and the possible need for surgery.

No one could make up a story such as this, but it is all too common in our current healthcare system. None of the individuals involved in my wife’s care was hostile, rude or uncaring. They were all working within a system, however, that does not place value on being patient-centric. Like most of our care delivery system, perhaps with “elite” private and academic health centers the poster-children, it is more about “them” than it is about “us” when we are patients. Building beautiful new facilities and having the latest technology has little value when the system forgets why it exists — to provide compassionate, timely, high-quality care for individuals who are in pain, frightened and at the mercy of the system.

By the way, the fact that I was able to “pull strings” to accomplish even what was eventually done is not something of which I am proud. Like any husband, I was willing to do all that I could to make sure my wife was cared for in the best way possible. I am no different from any other husband, wife, son or daughter who wants only the best for their loved one. No one deserves anything less.

We should always remember that as physicians and healthcare workers, we are here to serve patients. As the founder of modern nursing, Florence Nightingale, said more than a century and a half ago: “Apprehension, uncertainty, waiting, expectation, fear of surprise, do a patient more harm than any exertion.”

Apollo 13 returned from moon orbit safely, and I hope we have the wisdom, foresight and ability to work together in teams to rescue our ailing healthcare delivery system.

I look forward to your comments, until next time.

Striving to bring quality to life,
Allen R. Nissenson, MD

To make sure you receive a notification when a new blog is posted, click here!

To comment on this post click here!

I belong to a group of Chief Medical Officers that meets quarterly to discuss current and future challenges in the healthcare system.  The CMOs represent a wide variety of healthcare organizations, including integrated care systems, pharmaceutical companies, insurers, laboratory and pharmacy providers, and multispecialty physician groups.  I am the sole CMO from a chronic disease provider organization.  We recently met with Mike Leavitt, the former governor of Utah and former secretary of Health and Human Services under George W. Bush.  Mr. Leavitt is currently founder and chair of Leavitt Partners, a consulting firm in healthcare.  This was an intimate session with 10 or so CMOs participating with Governor Leavitt, and I was impressed with his view of the future of healthcare over the next four to six years.  The key points include the following — I have added what I see as the direct relevance for the future of kidney care:

1. Shift from compassion to dispassion. With the global economic crisis, including the serious economic downturn in the United States, dispassion (NOT the opposite of compassion) is becoming the decision driver rather than compassion.  Countries realize they cannot do everything for everyone.  In the United States this means that “good enough” will become an important part of the construct of healthcare delivery.
   Relevance for kidney care: We need to start being far more proactive in determining who is really going to benefit from dialysis, as well as when to work with families and patients when ongoing dialysis is just not improving a patient’s quality of life.  End-of-life care/palliative care need to be addressed much more openly and aggressively.
2. Networks. One only needs to look at the airline industry to see that networks have become an essential way of doing business in order to survive.  The future of healthcare will depend on robust networks, and in order to play providers have to form them or be part of them.
   Relevance for kidney care: It is likely that continued consolidation in the dialysis industry will occur, and will be required in the new healthcare world.  Survival as individual facilities or physicians will be increasingly difficult.  Should ACOs or other models of integrated care management continue to expand, nephrologists need to find their place in these networked organizations.
3. Buses, taxis and limos. Think of the city manager charged by the citizens to develop a public transportation system.  He decides taxis would be convenient and cost-efficient.  Over a few years, people in other cities hear about this, like it and move to the “taxi” city.  Soon the system is overloaded, more taxis are needed, taxes rise, and people start moving out or the wealthy stay but hire limos to continue to provide convenience.  The city decides, in order to provide transportation, it must switch to buses.  People complain, but the bus gets them where they are going.  In healthcare we are moving to getting from A to B, regardless of convenience — regionalized services, waiting periods and the like will all be necessary in a world of growing demand and increasingly limited resources, unless consumers pay for the level of convenience they want.  The question is can quality NOT be tiered despite tiering of convenience?
   Relevance to kidney care: Nephrologists are the gatekeepers of quality.  This responsibility cannot be delegated to other entities.  This will be increasingly important as more and more care will be “good enough”.  Nephrologists must be part of such discussions and always continue to advocate for what is best for their patients.
4. Three competitive entities. These are large multi-specialty groups, insurers and hospitals.  None of the three has all of the ingredients, and the real question is who is the “general contractor” for the healthcare delivery in a city or region.  General consensus is that of the three, hospitals have the least clue and have been the least innovative in preparing for the new world.
   Relevance to kidney care: Be wary of aggressive moves by hospitals to acquire practices or tie nephrologists into exclusive agreements.  This sector of the industry seems the most “dinosaur-like,” and maintaining agility in nephrology practice is one of the key ingredients to continued success.
5. Cinderella and the ball. Speed and timing will mean everything in determining winners and losers.  The smart players will be inching toward the door of the ballroom at about 11:50 p.m. so that they beat the stampede to the midnight pumpkins and get trampled in the process.  The movement toward integration of the care systems is moving more rapidly than most people think.
   Relevance to kidney care: It is essential that nephrologists stay educated on the moving playing field of healthcare in general and nephrology in particular.  Know who the leading players are, and be prepared to initiate a partnership/collaboration when the stars align — in this case, early in is likely to be the best approach, if you have the right partner.
6. Kodak moment. Kodak had the dilemma of basing its brand on film, even as the world of digital photography was developing.  It was promoting the latter while still basing its core business on the former.  The winners in the new care paradigm are those who have figured out what disruptive technology is coming and how to prepare for it.
   Relevance to kidney care: Nephrologists must be proactive in testing new approaches to delivering kidney care.  Such things as every-other-day dialysis, more frequent dialysis in-center and wearable devices are all talked about, and if they provide significant incremental clinical advantages, patients should have access to these.  The barriers of inadequate reimbursement, however, are real but starting slow, and demonstrating overall value (quality/cost) can push the curve substantially.
7. Leaven in the loaf. It is clear that the first target for realigning healthcare will occur at the state level with intense pressure on Medicaid programs to constrain costs for states that are in the midst of massive budget deficits.  This could be fertile ground for experimenting.  Insurance exchanges are likely to grow much more rapidly than initially thought, with employers moving employees into these systems to control costs and shift costs to the employee.
   Relevance to kidney care: Erosion of Medicaid programs will significantly wear down CKD and ESRD patient care.  Nephrologists must be proactive in their individual states to ensure that this vulnerable population is protected.  Similarly, insurance exchanges may significantly decrease fees paid to providers, threatening access of patients to care and the ability of nephrologists and dialysis providers to serve these patients.  An urgent threat is the omission of Medicare Secondary Payer (MSP) requirements for these exchanges, essentially resulting in patients with employer-based insurance being moved to Medicare immediately if they have ESRD rather than waiting the current 30 months.  As recently articulated by RPA/ASN/ASPN, “Patients with End Stage Renal Disease (ESRD) are among the most vulnerable of all Medicare patient populations. It is important to account for the needs of these patients by maintaining funding for ESRD care at current levels. The Medicare ESRD program was recently transitioned to a bundled payment system; the transition included an across-the-board payment reduction. Subjecting the program to further cuts would jeopardize patient access to readily available, high quality dialysis care. We urge you to consider applying the Medicare Secondary Payer (MSP) provision to the recently enacted health exchanges. This proposal not only will maintain current funding levels for ESRD care, but will also potentially achieve billions of dollars of savings for the Medicare program. ASN, ASPN, and RPA urge you to protect ESRD care by keeping dialysis reimbursements whole, and instead consider innovative solutions such as application of the MSP provisions to health exchanges.”*

As the hockey great Wayne Gretzky said, “You miss 100% of the shots you don’t take”.

This approach, and the urgency we and our patients face, is described in an African proverb:  “If you want to go quickly, go alone, if you want to go far, go together.” We have to go far, quickly, and that means we have to quickly find a way to change the world’s consciousness about exactly what we are facing and how we have to work to solve it.

Nephrologists need to look into the future, identify partners whose vision they share, and then together shape the opportunities for delivering even better care and better outcomes despite shrinking resources.

I look forward to your comments, until next time.

Striving to bring quality to life,

Allen R. Nissenson, MD

To make sure you receive a notification when a new blog is posted, click here!

To comment on this post click here!

*ASN, RSPN, RPA letter to Congress, October 13, 2011.

I was at the Hollywood Bowl recently—a magnificent outdoor concert facility built in 1919, featuring incredibly diverse music from jazz to pop to classical to Broadway. Small boxes are available for seating and my wife Charna and I have a series—four seats in a box. We invite another couple, and Charna, who is an amazing cook, prepares an incredible meal, and life is good. This evening we were going to experience an all-Beethoven concert—two romances, then Symphony no. 8 and ending with Symphony no. 5.  The guest artist and conductor was Itzhak Perlman. Perlman was born in 1945 in Israel to parents of very modest means—his father was a barber. At age four Perlman contracted polio and has had no movement in his legs since that time. He became a violin virtuoso in high school and has never looked back. He is truly one of the great musicians of his generation.

When Itzhak Perlman came out on the stage that evening, walking slowly with his ever-present crutches, the audience was first quiet then burst into applause. As he made his way across the stage and up a three-step platform, however, the applause stopped then began again—as if this was a major accomplishment—Perlman waved his hand to indicate that the acknowledgement was not necessary. He didn’t consider what he did to be remarkable in any way, just a normal part of his life and his job.

While listening to the first of the two romances I could not help but reflect about the lives our patients lead, and the way we all, as caregivers, often forget the courage they exhibit every day, whether it is a day coming to dialysis or a day recovering.  Each day these folks get out of bed with the same desires, hopes, dreams that healthy people have. But, in addition, they have the concerns and worries about their health, that day and in the future, about how long they will live and be able to provide for and be with their families, how they will be able to continue to be productive members of society.

How many of us, however, when we make rounds in the dialysis facility, think about these issues and what our patients are really going through and thinking? What is the balance of conversation between discussing lab tests and the need for being compliant with instructions compared with how things are really going in the patient’s life? We have become very complacent about the patients we treat—we oversee an incredibly complex technical procedure, carried out in seriously ill patients, generally safely and effectively. But is that really the best we can do? Next time you make rounds think about what each patient is going through—not just when on dialysis, but holistically, and think about how you can really make each patient’s life better. If our discipline can learn to do this effectively not only will patients be better off, but so will we!

As Hippocrates said almost 2500 years ago: “Some patients, though conscious that their condition is perilous, recover their health simply through their contentment with the goodness of the physician.”

I look forward to your comments, until next time.

Striving to bring quality to life,

Allen R. Nissenson, MD

To make sure you receive a notification when a new blog is posted, click here!

To comment on this post click here!

The ESRD Networks have been an integral part of the quality oversight of the ESRD program for decades now. Originally 44 such organizations, now officially 18, cover the country and have a contractual relationship with CMS based on specific performance and deliverables. The most recent iteration of Network contracts holds these organizations accountable for some specific clinical outcomes of dialysis facilities, in particular the fraction of patients with AVFs.  This focus for CMS and the Networks is part of the Fistula First Initiative, an outstanding national quality improvement program designed  to increase the number of AVFs in U.S. hemodialysis patients—an area where we lagged significantly behind other parts of the world. And who could argue with this focus? Everyone knows that AVFs are associated with fewer infections and episodes of clotting than grafts or catheters and the latter in particular lead directly to increased hospitalizations, mortality and significant increases in the costs of care.

An intense focus on AVFs, however, has some unintended consequences, including multiple surgical procedures.  Poorly constructed AVFs do not function and may lead to significant morbidity. Until permanent access is functional, catheters are required for carrying out dialysis with all of the attendant risks these convey. Judicious use of grafts is a far better alternative. Ah, but there is the rub—dialysis facilities and now Networks are not “graded” on how few catheters their patients have, but only on how many fistulas, no matter what the cost.

The misalignment this state of affairs causes was clearly illustrated to me in a recent call I had with an ESRD Network MRB chair and Executive Director. They were very concerned because their Network was getting intense pressure from CMS because the facilities in their region had among the lowest AVF rates in the country.  As it turns out, however, this Network has the lowest catheter rate. As we have been able to show in DaVita facilities, the facility can clearly impact catheter rates after patients enter the facility, with clear process approaches that drive permanent access placement and catheter removal.  It is less clear, however, how facilities impact, and can be held accountable for, whether a patient gets an AVF or a graft.  That is the domain of the attending nephrologist and the vascular surgeon, who are the ones who should be held accountable.

So, should the Network in question be viewed by CMS as a poorly functioning one because of somewhat low AVF rates or one of the best because of great catheter rates? If we return to the old adage, Do No Harm, forcing placement of AVFs where surgeons are not skilled in their construction or patients may not be suitable, seems to be far less important than focusing on minimizing the use of catheters. In the ideal circumstance, there would be great surgical support and both goals—more AVFs and fewer catheters—would be possible, few real life situations fit that description. Making tough choices is a part of the Art of Medicine, and for me, intense focus on catheter removal should clearly take priority. Penalizing Networks and facilities focusing only on AVFs, Fistula First, rather than Catheter Last is the wrong policy approach.  It creates unproductive friction between components of the care system that should be working closely together.

As articulated in Wikipedia:  “The law of unintended consequences is an…idiomatic warning that an intervention in a complex system always creates unanticipated and often undesirable outcomes.  Akin to Murphy’s law, it is commonly used as a…humorous warning against the hubristic belief that humans can fully control the world around them.”

I look forward to your comments, until next time.

Striving to bring quality to life,

Allen R. Nissenson, MD

To make sure you receive a notification when a new blog is posted, click here!

To comment on this post click here!

The New York Times recently highlighted a new program being introduced as part of the evaluation of applicants for medical school.  A handful of medical schools are now assessing social skills, having the applicants interview nine “patients” with serious social or ethical problems.  Not only are social skills assessed, but also the ability of the applicants to work together in small teams.  As nephrologists, we know patients with chronic illnesses, including CKD/ESRD, are among the most needy in this regard, requiring physicians who listen and are able to work effectively in teams, whether within their practice, with other doctors, or with the interdisciplinary team in a dialysis facility.

A recent medical crisis with my Mother made me think hard about how physicians, patients and caregivers communicate nowadays in the world of technology-driven medicine and electronic communication.  Although my mother does not have CKD/ESRD, she does have significant chronic illnesses.  She is 85 years old and as mentally sharp and energetic as she was 50 years ago.  Over the years, she has developed diabetes, hypertension and, more recently, slowly progressive liver dysfunction (“cryptogenic cirrhosis”).  The latter has been the most problematic, leading to two hospitalizations over the past 3 years with hepatic encephalopathy.  Both of these hospitalizations were handled quickly and efficiently, poor control of blood sugar and blood pressure had pushed her over the metabolic edge, and she quickly recovered with appropriate attention to these issues.

A month ago, I got a call from my sister telling me Mom was admitted again, confused, agitated and disoriented.  This seemed like another one of her metabolic “episodes”, but the ER physician decided to order a brain MRI, EEG and neurology consult.  He did not pull up her medical records or listen to the history given by my sisters.  The MRI showed a small area of scarring (likely from a fall a few years ago) and the EEG was “abnormal”.  The neurologist could not interview my mom, who was still confused, and told my sisters that mom had status epilepticus based on the EEG and started her on high dose Keppra.  One could predict the result- extreme fatigue, inability to ambulate and growing depression.

When I got this news, I called the neurologist to get the direct information on what had happened.  The neurologist who made the diagnosis was not on hospital duty any longer and her associate was, but was not available.  I asked for an email address and was told, “his policy is not to provide email addresses to patients or families”.  The next day, I got a message that he also had spoken to my sisters and that, despite my being a physician, his policy was only to speak with a single family member.  I was finally able to contact the initial neurologist who was the “seizure specialist” of the group, who described why she made the diagnosis she did.

I asked if it was possible that the abnormal EEG was related to metabolic encephalopathy, since the clinical episode was so similar to previous episodes.  I also asked what the clinical manifestations of status epilepticus were- she could not answer either question but was adamant that the diagnosis was correct.  When I suggested tapering the Keppra to see if the now-corrected metabolic problems were the true precipitating cause, she stated that she would not consider that for at least a year.

I got a second opinion from a local academic institution- the chief of the epilepsy service interviewed my mom, reviewed the tests and immediately started tapering the Keppra.  He stated that the diagnosis was incorrect but an honest mistake, since the neurologist couldn’t interview my mom and did not have direct access to her previous records.  After 3 weeks of slowly tapering off the Keppra, my mom is back to her normal, ambulating, bubbly self.

The point?  Poor communication, over-reliance on high-tech procedures and inability or unwillingness to interact with the family – when the patient was unable to provide clear information – were at the root of the mistake.  Such situations occur daily with patients on dialysis and the increasing reliance of nephrologists on physician extenders further extends the gap between patient and doctor.  I hope that nephrologists will again reexamine the value of spending time with patients,  listening to them and better understanding what they want and need.  The technical aspects of dialysis are generally well performed but to truly deliver holistic care, we must all remember this is done one patient at a time, at the bedside, and it takes time and commitment.

As made famous in Cool Hand Luke:  “What we have here is a failure to communicate”.  That should never be the case in the practice of the art of medicine.

I look forward to your comments, until next time.

Striving to bring quality to life,

Allen R. Nissenson, MD

To make sure you receive a notification when a new blog is posted, click here!

To comment on this post click here!