Archive for category Drugs

NHS sues Gaviscon maker Reckitt Benckiser

http://www.bbc.co.uk/news/business-12539197 22 February 2011

The NHS in England has launched legal action against Reckitt Benckiser, maker of heartburn medicine Gaviscon.

According to High Court documents, Health Secretary Andrew Lansley is leading the action on behalf of health authorities and primary care trusts.

The Department of Health refused to comment on the subject of the suit.

Reckitt Benckiser was fined £10m last year for abusing its dominant market position in the supply of heartburn remedies to the NHS.

A spokesman for Reckitt said the company could not comment as it had not been served with any papers.

Papers lodged at the High Court show Reckitt is being sued collectively by all 10 Strategic Health Authorities and 144 Primary Care Trusts in England, as well as Andrew Lansley as Secretary of State for Health.

‘Dominant position’

The Office of Fair Trading (OFT) said in October last year that Reckitt had restricted competition in the supply of heartburn medicines.

The household products maker withdrew the original Gavison from the NHS in 2005 and patients were transferred to Gaviscon Advance Liquid.

This happened after Gaviscon’s patent had expired, but before a generic name had been assigned to it, the OFT said.

That meant that prescriptions were issued for Gaviscon Advance, rather than pharmacists being able to choose a cheaper generic alternative.

The OFT’s inquiry followed an investigation by the BBC’s Newsnight programme in 2008.

Gaviscon is one of the most heavily prescribed medicines within the NHS.  Confidential papers leaked to the programme by a whistleblower showed it was also very profitable, with a gross margin of 77% in 2003.

The then-chief executive of the OFT, John Fingleton, said at the time: “This case underlines our determination to prevent companies with a dominant position in a market from using their strength to seek to restrict competition from rivals”.

In response to the OFT’s fine, Reckitt said that it had believed it was acting within the law at the time and respected the watchdog’s findings.

, , , ,

Leave a comment

Selling Sickness to the Well

http://icarusfilms.com/new2005/sell2.html Selling Sickness
Newsweek Interview with Ray Moynihan

A new book looks at how pharmaceutical companies are using aggressive marketing campaigns to turn more people into patients.

By Jennifer Barrett

Aug. 2, 2005 – There are few Americans these days who aren’t popping pills to treat a complaint, or to prevent one. From headache medicine to cholesterol-lowering drugs to sexual-dysfunction aids, there seems to be a remedy for every disorder out there and even some we didn’t realize existed (until we saw the ad, that is). In their new book, Selling Sickness: How the Worlds Biggest Pharmaceutical Companies Are Turning Us All Into Patients (Nation Books), Ray Moynihan and Alan Cassels examine how the drug industry has transformed the way we think about physical and mental health and turned more and more of us each year into customers. NEWSWEEKs Jennifer Barrett spoke with Moynihan, a medical writer for the Milbank Memorial Fund in New York and a regular contributor to the British Medical Journal, about how and why drug makers have begun targeting people who aren’t sick. Excerpts:

NEWSWEEK: You write that drug makers now aggressively target the healthy. Why?

Ray Moynihan: The book opens with a quote from a former Merck CEO that it was a shame he wasn’t able to make Merck more like the chewing-gum maker, Wrigleys, because then he’d be able to “sell to everyone.” I think that does drive the marketing machinery of the drug companies now. Drug companies target lots of sick people and make fabulous drugs that extend lives and ameliorate suffering. But the so-called preventives are where the big money are: like the bone-density drugs or the cholesterol [-lowering] drugs. Increasingly were seeing the marketing shift to those types of drugs. People talk about the “worried well.” There are many ways in which the drug companies target those people.

You mean people who are well but worried about being sick? How are they targeted?

The use of celebrities is now a standard way in which drug companies don’t just promote their drugs but try and change public awareness, public thinking and public perceptions about illness. In some cases the disease phrasing is legitimate and welcome. But when you have celebrities trying to change the way we think about sexual difficulties or stomach problems or symptoms of stages of life, these are insidious campaigns.

Why celebrities? I might take Serena Williams’ advice on a brand of tennis racket but menstrual migraine medication?

[Laughs.] There’s actually a whole mini industry of celebrity brokers who bring together celebrities and drug companies. I’ve interviewed one of the brokers who talked about the reason celebrities work so well in getting people to think about conditions and to go to their doctors.

Why do they work so well?

Because people trust celebrities. But they are not telling you often enough that they are on the [drug company’s] payroll. Of course, if they did tell you as often as they should, your trust might diminish somewhat.

Aren’t there enough sick people that the drug companies can target? Why try and convince others they’re sick?

The marketing people and the sophisticated PR people who work for them are doing what shareholders demand of them. They’re looking for ways to maximize markets. One way is to redefine more and more people as sick. There’s an informal alliance between the drug companies and aspects of the medical profession and aspects of the patient advocacy world who all seem to have interests in defining more and more people as ill. We look at this condition by condition in the book, and what you see is a similar formula or process at work. Every time a panel of experts come together, they want to nudge the boundaries a little further out, whether its mental illness, cholesterol or high blood pressure.

How do you think this is affecting the American psyche?

Asclepius was the Greek god for healing and one of his children was Panacea. She is one we all worship no matter if were Jewish or Christian or Muslim. We all want a panacea, particularly if were vulnerable or sick. The trouble is that there are vast commercial and professional forces trying to exploit the vulnerability we have and exploit our desire for a panacea. I don’t know what is happening to the American psyche. But I see a country bombarded with advertisements. We’re seeing fear of disease, decay and death becoming a central part of life. Id like people to investigate the psychic impact of being told 10 times a day you might actually be sick.

You’re from Australia, though you focus on the United States for this book. Is America unique?

The marketing strategies of pharmaceutical companies play out globally. However, the U.S. is the epicenter of the selling of sickness, of disease-mongering. Americans make up less than 5 percent of the worlds population but the U.S. makes up 50 percent of the drug market.

Really?

That doesn’t mean the U.S. takes 50 percent of pills.

That’s a relief.

But it does account for half of total spending on drugs. It’s still extraordinary. And it’s at the high end of pill taking.

Why is that?

The U.S. is different because it allows direct-to-consumer advertising [of prescription medications], which has taken off in a huge way in the past eight to 10 years. It’s been around a long time, but there was a loosening of the regulations in the mid- to late ’90s. New Zealand, too, is [unusual] in the world that way. In Australia and other countries, there is a strict ban on direct to consumer marketing. But so-called disease awareness programs, heavily funded by pharmaceutical companies, are not banned. So marketing strategies do play out in other places as well.

Have you heard from any drug companies since your book came out?

It’s been out for a month in Australia, and there hasn’t been anything out there to counter the journalism in my book. There’s been a very strong silence. The worrying thing about that is that it makes me think that I might be right.

If so, what do you hope would come from the book?

I hope a few more people become a bit more skeptical about the claims being made to them about drugs and disease, about the labels that are being attached to them, and the conditions they’re being told they have. Its time for all of us to be a bit more skeptical.

2005 Newsweek, Inc.

 

,

Leave a comment

What’s Wrong With the Drug War?

http://www.drugpolicy.org/drugwar/ Drug Policy Alliance

Everyone has a stake in ending the war on drugs. Whether you’re a parent concerned about protecting children from drug-related harm, a social justice advocate worried about racially disproportionate incarceration rates, an environmentalist seeking to protect the Amazon rainforest or a fiscally conservative taxpayer you have a stake in ending the drug war.

U.S. federal, state and local governments have spent hundreds of billions of dollars trying to make America “drug-free.” Yet heroin, cocaine, methamphetamine and other illicit drugs are cheaper, purer and easier to get than ever before. Nearly half a million people are behind bars on drug charges – more than all of western Europe (with a bigger population) incarcerates for all offenses. The war on drugs has become a war on families, a war on public health and a war on our constitutional rights.

Many of the problems the drug war purports to resolve are in fact caused by the drug war itself. So-called “drug-related” crime is a direct result of drug prohibition’s distortion of immutable laws of supply and demand. Public health problems like HIV and Hepatitis C are all exacerbated by zero tolerance laws that restrict access to clean needles.  The drug war is not the promoter of family values that some would have us believe. Children of inmates are at risk of educational failure, joblessness, addiction and delinquency. Drug abuse is bad, but the drug war is worse.

Few public policies have compromised public health and undermined our fundamental civil liberties for so long and to such a degree as the war on drugs. The United States is now the world’s largest jailer, imprisoning nearly half a million people for drug offenses alone. That’s more people than Western Europe, with a bigger population, incarcerates for all offenses. Roughly 1.5 million people are arrested each year for drug law violations – 40% of them just for marijuana possession. People suffering from cancer, AIDS and other debilitating illnesses are regularly denied access to their medicine or even arrested and prosecuted for using medical marijuana. We can do better.

Leave a comment

Concern over generic drugs

http://www.adelaidenow.com.au

THE nation’s pharmacists have been urged to come clean about the sale of generic medicines, amid concern they can cause confusion and are not always a cheaper alternative.

New research shows it is now commonplace for Australians to be asked, at the pharmacy counter, if they want a generic version of the brand-name drug their doctor has prescribed.

Nine out of 10 respondents to a Galaxy Poll said they had been offered a generic alternative within the past two years, and more than half (55 per cent) said they did not ask about price before accepting the offer.

Melbourne-based pharmacist Gerald Quigley said that although there was a view that generics were always “a better deal”, sometimes they were no cheaper than a popular branded rival.

Generics also introduced new risks when given to vulnerable members of the community, he said, particularly elderly people who need to take an array of pills every day.

“When your yellow-and-green capsule suddenly becomes a blue-and-red capsule, it is amazing how many older people say: `I can’t remember taking that before, and I just won’t take it’,” Mr Quigley said.

“… There needs to be a lot more discussion about this to make sure that patients get what they expect and what they trust.”

Drug companies can produce a generic version of a popular medicine – containing the same active compounds but different in appearance – once the patent held by its original maker has expired.

The poll of more than 500 Australian adults, commissioned by drug company Nycomed Australia and released today, found that 42 per cent of people now accept the offer of a generic “every time” while 32 per cent did so “most times”.

One in five (21 per cent) worried that taking a generic drug could lead them to receiving the wrong medicine, while eight per cent said they never accepted the offer of a generic.

Pharmacy Guild of Australia national president Kos Sclavos said the poll results contained some positive news, and that it was competition between the generic and branded drug manufacturers that put downward pressure on prices.

“From the Government’s point of view, where there is a generic they can force the price down … That’s one of the reasons why medicines are becoming more affordable,” Mr Sclavos said.

“And, from a pensioner point of view, every cent makes a difference.”

Generics have been available in Australia since the early 1990s but, Mr Sclavos said, sale volumes had remained low compared with other countries, such as the UK.

There were only a “half a dozen” cases where the generic and branded versions of a drug were the same price, he said. In most cases, the saving was 20 to 30 cents, but could be as high as $20.

“I’m actually pleased with the (poll) research because it shows our pharmacists are doing the right thing … Five or six years ago we were in trouble for not doing that,” Mr Sclavos said of the now commonplace offer of a generic.

“Obviously, there is still more work to do in terms of patients getting confused about it, and that’s something we’ll take on board and act upon.”

He said many pharmacies offered pill packaging services to help elderly patients take their array of daily medications correctly.

The Federal Government has committed $10 million for a public awareness campaign to address confusion surrounding generic drugs.

 

1 Comment

Alcohol responsible for nearly half of treatment for alcohol and other drug use

Australian Institute of Health & Welfare  3 December 2010

Alcohol remains the most common drug Australians seek treatment for, making up almost half of all drug and alcohol related treatment episodes in 2008–09, according to a report released today by the Australian Institute of Health and Welfare (AIHW).

The report, Alcohol and other drug treatment services in Australia 2008–09: Report on the National Minimum Data Set, presents information on publicly funded alcohol and other drug treatment services and their clients in 2008–09.

It shows that in 2008–09, there were more treatment episodes for alcohol than any other drug type, with this proportion having risen four years in a row.

Around 143,000 alcohol and other drug treatment episodes were provided in Australia in 2008-09.

‘Alcohol is the most widely used drug in the Australian community, and is also the drug for which most people sought treatment in 2008–09,’ said Amber Jefferson, Head of Institute’s Drug Surveys and Services Unit.

‘In 2008–09, 46% of all treatment episodes were for alcohol, compared with 38% in 2002–03.’

When it comes to illicit drugs, treatment for heroin use has declined and treatment for cannabis use has remained stable.

‘Treatment for heroin use has been declining over time to 10% in 2008–09, compared with 18% in 2002–03,’ Ms Jefferson said.

‘Treatment for cannabis use has remained stable at about 23%. Amphetamine treatment as a proportion of all episodes was 9% in 2008–09, compared with 11% in 2002–03.’

‘The largest group of clients were men aged 20 to 29 years—and this finding has been consistent over time,’ Ms Jefferson said.

Younger clients were more likely to receive treatment for cannabis use and older clients for alcohol use.

As with previous years, counselling was more common than any other type of treatment, and was provided in about 2 in 5 episodes.

The proportion of clients in withdrawal management (detoxification) has declined since 2002–03, even though the number of these episodes has increased overall.

The vast majority of treatment episodes (96%) were for people seeking treatment for their own drug use, as opposed to people seeking treatment for someone else’s drug use (4%).


Leave a comment

Alcohol More Dangerous Than Heroin, Study Finds

by The Associated Press

November 1, 2010

British researchers found that alcohol damages nearly all organ systems when drunk in excess, and is involved in more crime than most other drugs, including heroin.

Alcohol is more dangerous than illegal drugs like heroin and crack cocaine, according to a new study.

British experts evaluated substances including alcohol, cocaine, heroin, ecstasy and marijuana, ranking them based on how destructive they are to the individual who takes them and to society as a whole.

Researchers analysed how addictive a drug is and how it harms the human body, in addition to other criteria like environmental damage caused by the drug, its role in breaking up families and its economic costs, such as health care, social services, and prison.

Heroin, crack cocaine and methamphetamine, or crystal meth, were the most lethal to individuals. When considering their wider social effects, alcohol, heroin and crack cocaine were the deadliest. But overall, alcohol outranked all other substances, followed by heroin and crack cocaine. Marijuana, ecstasy and LSD scored far lower.

What governments decide is illegal is not always based on science.

The study was paid for by Britain’s Centre for Crime and Justice Studies and was published online Monday in the medical journal, Lancet.

Experts said alcohol scored so high because it is so widely used and has devastating consequences not only for drinkers but for those around them.

“Just think about what happens [with alcohol] at every football game,” said Wim van den Brink, a professor of psychiatry and addiction at the University of Amsterdam. He was not linked to the study and co-authored a commentary in the Lancet.

When drunk in excess, alcohol damages nearly all organ systems.  It is also connected to higher death rates and is involved in a greater percentage of crime than most other drugs, including heroin.

But experts said it would be impractical and incorrect to outlaw alcohol.

“We cannot return to the days of prohibition,” said Leslie King, an adviser to the European Monitoring Centre for Drugs and one of the study’s authors. “Alcohol is too embedded in our culture and it won’t go away.”

King said countries should target problem drinkers, not the vast majority of people who indulge in a drink or two. He said governments should consider more education programs and raising the price of alcohol so it isn’t as widely available.

Experts said the study should prompt countries to reconsider how they classify drugs. For example, last year in Britain, the government increased its penalties for the possession of marijuana.  One of its senior advisers, David Nutt — the lead author on the Lancet study — was fired after he criticized the British decision.

“What governments decide is illegal is not always based on science,” said van den Brink. He said considerations about revenue and taxation, like those garnered from the alcohol and tobacco industries, may influence decisions about which substances to regulate or outlaw.

“Drugs that are legal cause at least as much damage, if not more, than drugs that are illicit,” he said.

 

Leave a comment

Drugs in Portugal: Did Decriminalisation Work?

http://www.time.com

By Maia Szalavitz   26th April 2009

At the recommendation of a national commission charged with addressing Portugal’s drug problem, jail time was replaced with the offer of therapy.

The argument was that the fear of prison drives addicts underground and that incarceration is more expensive than treatment — so why not give drug addicts health services instead?

Under Portugal’s new regime, people found guilty of possessing small amounts of drugs are sent to a panel consisting of a psychologist, social worker and legal adviser for appropriate treatment (which may be refused without criminal punishment), instead of jail.

The question is, does the new policy work? At the time, critics in the poor, socially conservative and largely Catholic nation said decriminalizing drug possession would open the country to “drug tourists” and exacerbate Portugal’s drug problem; the country had some of the highest levels of hard-drug use in Europe. But the recently released results of a report commissioned by the Cato Institute, a libertarian think tank, suggest otherwise.

The paper, published by Cato in April, found that in the five years after personal possession was decriminalized, illegal drug use among teens in Portugal declined and rates of new HIV infections caused by sharing of dirty needles dropped, while the number of people seeking treatment for drug addiction more than doubled.

Judging by every metric, decriminalization in Portugal has been a resounding success,” says Glenn Greenwald, an attorney, author and fluent Portuguese speaker, who conducted the research. “It has enabled the Portuguese government to manage and control the drug problem far better than virtually every other Western country does.”

Compared to the European Union and the U.S., Portugal’s drug use numbers are impressive. Following decriminalization, Portugal had the lowest rate of lifetime marijuana use in people over 15 in the E.U.: 10%. The most comparable figure in America is in people over 12: 39.8%. Proportionally, more Americans have used cocaine than Portuguese have used marijuana.

The Cato paper reports that between 2001 and 2006 in Portugal, rates of lifetime use of any illegal drug among seventh through ninth graders fell from 14.1% to 10.6%; drug use in older teens also declined. Lifetime heroin use among 16-to-18-year-olds fell from 2.5% to 1.8% (although there was a slight increase in marijuana use in that age group). New HIV infections in drug users fell by 17% between 1999 and 2003, and deaths related to heroin and similar drugs were cut by more than half. In addition, the number of people on methadone and buprenorphine treatment for drug addiction rose to 14,877 from 6,040, after decriminalization, and money saved on enforcement allowed for increased funding of drug-free treatment as well.

Portugal’s case study is of some interest to lawmakers in the U.S., confronted now with the violent overflow of escalating drug gang wars in Mexico. The U.S. has long championed a hard-line drug policy, supporting only international agreements that enforce drug prohibition and imposing on its citizens some of the world’s harshest penalties for drug possession and sales. Yet America has the highest rates of cocaine and marijuana use in the world, and while most of the E.U. (including Holland) has more liberal drug laws than the U.S., it also has less drug use.

“I think we can learn that we should stop being reflexively opposed when someone else does [decriminalize] and should take seriously the possibility that anti-user enforcement isn’t having much influence on our drug consumption,” says Mark Kleiman, author of the forthcoming When Brute Force Fails: How to Have Less Crime and Less Punishment and director of the drug policy analysis program at UCLA. Kleiman does not consider Portugal a realistic model for the U.S., however, because of differences in size and culture between the two countries.

But there is a movement afoot in the U.S., in the legislatures of New York State, California and Massachusetts, to reconsider our overly punitive drug laws. Recently, Senators Jim Webb and Arlen Specter proposed that Congress create a national commission, not unlike Portugal’s, to deal with prison reform and overhaul drug-sentencing policy. As Webb noted, the U.S. is home to 5% of the global population but 25% of its prisoners.

At the Cato Institute in early April, Greenwald contended that a major problem with most American drug policy debate is that it’s based on “speculation and fear mongering,” rather than empirical evidence on the effects of more lenient drug policies. In Portugal, the effect was to neutralize what had become the country’s number one public health problem, he says.

“The impact in the life of families and our society is much lower than it was before decriminalization,” says Joao Castel-Branco Goulao, Portugual’s “drug czar” and president of the Institute on Drugs and Drug Addiction, adding that police are now able to re-focus on tracking much higher level dealers and larger quantities of drugs.

Peter Reuter, a professor of criminology and public policy at the University of Maryland, like Kleiman, is skeptical. He conceded in a presentation at the Cato Institute that “it’s fair to say that decriminalization in Portugal has met its central goal. Drug use did not rise.” However, he notes that Portugal is a small country and that the cyclical nature of drug epidemics — which tends to occur no matter what policies are in place — may account for the declines in heroin use and deaths.

The Cato report’s author, Greenwald, hews to the first point: that the data shows that decriminalization does not result in increased drug use. Since that is what concerns the public and policymakers most about decriminalization, he says, “that is the central concession that will transform the debate.”
Read more: http://www.time.com/time/health/article/0,8599,1893946,00.html#ixzz11LTxUuei

 

2 Comments

Online Assessments helps diagnose Mental Illness

There may be some benefits in diagnosing people without seeing or speaking to them BUT I find this idea quite dangerous.  The Black Dog Institute admit to having a close relationship with the pharmaceutical industry and say that :

‘New drugs have brought great advances in recent years in the treatment of the mood disorders. The Black Dog Institute is at the forefront of research into therapeutic benefits of drug treatments, and works closely with pharmaceutical companies.  For example, Institute researchers conduct clinical trials of new drugs.  Institute specialists often speak at medical conferences, including conferences sponsored by companies making medical or pharmaceutical products.

ABC News Online 24 October, 2010

It is hoped a new online mental health self-assessment service will help doctors achieve more accurate diagnoses for their patients.

Research by The New South Wales Black Dog Institute found sufferers of mental illness are likely to reveal more information about their condition online.

The institute has created the mood assessment program, or MAP, which is now available to GPs and psychologists all over Australia.

Patients can complete the assessment at home and doctors do not see the patients’ answers, but receive an automatically generated report.

The institute’s Professor Gordon Parker says MAP is based on nearly a quarter of a century of the clinical expertise.

“The MAP is unique. No other computerised program offers such a thorough assessment of depressive illness,” he said.

“It provides referring practitioners with a range of information about their patient including depressive subtype, likelihood of bipolar disorder, personality predisposition and social and environmental detail.”

He says MAP also alleviates the burden on consultation time.

Dr Louise Stone from the Australian College of Rural and Remote Medicine says the program can also help rural GPs to assess patients who cannot get to regular appointments.

“With the MAP program being online, one of the advantages of that approach is that rural and remote practitioners particularly can get an almost second opinion about the way they see their patients,” she said.

Leave a comment

WHO Knew If Flu Was True?

Tuesday, June 8, 2010

David H. Freeman www.msomed.org

Two recently released European reports have raised the possibility that scientists who helped fuel world fear of an H1N1 flu crisis were motivated by ties to drug companies enriched by the ensuing rush to stockpile medications.

The reports, which were from credible parties, including a Council of Europe committee and the British Medical Journal, noted that several of the World Health Organization scientists behind that agency’s pressuring of governments to take dramatic action in response to the flu had received consulting or other fees from the drug companies, but that WHO hadn’t bothered to identify these potential conflicts of interest. (Though the scientists in question had previously identified these ties in research-journal papers).

With H1N1 turning out to fall far short of the devastating pandemic WHO and others predicted, many of the world’s governments have ended up with vast unused stores of antiviral and other medications snatched up at WHO’s urging.

There’s no evidence that the scientists ginned up the warnings in order to channel sales to drug companies that had been good to them, and it seems unlikely that’s the case. Scientists widely agreed there was plenty of reason to fear that H1N1 could become widespread and deadly. And we surely want our scientists, institutions and governments to err on the side of caution in these matters.

It may even be that the rapid action taken by governments at WHO scientists’ prodding was at least partly why H1N1 appears to have been something of a dud, so that the wasted drugs are in a way a sign of WHO’s competence rather than its failure. (WHO actually continues to warn there’s still a real danger of H1N1 getting out of hand.)

Still, science is supposed to be tough on biases, and especially blatant conflicts of interest. It has long been standard to insist that scientists openly and clearly state any ties they have to any corporations when there is any chance that their work could be seen as benefiting those corporations. But there’s little question that conflict of interest remains a big problem in medical research.

A 2003 Journal of the American Medical Association review of conflict-of-interest meta-studies involving some 67 conflict-of-interest studies and 398 other research reports confirmed a strong correlation between industry sponsorship and positive findings. (I provide sources in Wrong for that last and the following points).  And the problem may be worse than it looks, because companies often disguise that they are behind certain findings by paying university researchers to put their names to studies actually conducted and written up by the companies–so-called “ghost authorship,” a problem that infects about three-quarters of industry-backed drug trials.

One study found According to another study, at least 30 percent of published medical researchers have been in a potential conflict-of-interest situation, and as few as 2 percent of researchers fully disclosed that fact. Every single one of the 170 psychiatric experts contributing to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) used to diagnose psychiatric disorders had financial ties to manufacturers of psychiatric drugs.

Remember this situation every time you hear of research that concludes a drug works well, or a new type of test is effective, or, yes, an infectious disease is about to wreak havoc on the world unless governments buy up all the treatments they can get their hands on. That’s not to say the specific research is likely to be wrong–but it’s another reason why we need to be wary consumers of research conclusions.

 

Leave a comment