Archive for the ‘Healthcare Topics @Blogfinger’ Category

Disease was once thought to be due to sin. We now know more,  but not enough.

Edited and reprinted from a prior edition of Blogfinger.

By Paul Goldfinger, MD, FACC

Most people have high hopes when they go to a doctor with a problem.  They want to believe that their physician will do some tests, find out what’s wrong, and then fix the situation. That is usually what happens. However, doctors sometimes do not recognize their own limitations. They may not  like to admit to themselves or to  patients that they do not know what’s wrong and what to do. The fact is that there is much that doctors do not know and there is much that they do which is unproven.

Sometimes a physician will suggest a second opinion. That is always a good idea, but the patient should go to someone who is a known authority in the field, even if it means a trip into New York or Philadelphia. Seeing a real expert may help put a halt to the doctor-shopping.  But what happens when no doctor knows the answer no matter how many you consult?  What happens when a situation hits the wall of the unknown?

There is a parallel universe where people reside with persistent symptoms despite the best efforts of doctors.  I know someone who has chronic vertigo. He has seen multiple specialists in New York City and has had every possible test for this condition. No diagnosis or effective  treatment has been found. The patient is still dizzy; he has been seen by professors without answers as well as charlatans who waste his time and money. He makes the best of it, but he keeps looking for another doctor who might help. He scours the internet for solutions.

Most everybody has something physical that bothers them, and if there is no definite diagnosis,  they try to get by, one way or another.   Some get conventional care from their doctors, while others resort to alternative therapies and OTC medications.  Many simply accept their fate and lead their lives without further tinkering by the medical establishment. But the ones who keep bouncing around from doctor to doctor, without diagnostic or therapeutic success,  are the ones who need the most guidance from the medical profession.

Physicians sometimes need to stop the snowballing of tests and opinions. Stopping means to admit that the patient’s problem cannot be solved, so the doctor needs to shift gears and focus on attentive and supportive symptom relief. It’s difficult to judge when that time has come. It has to be a decision made by the doctor and his patient. But once the decision is made, the physician  should continue to follow the patient, because you never know when an answer might appear.

Read Full Post »

Coffee time at Nagle’s. By Paul Goldfinger

This article was first published on Blogfinger in 2012. There is an update at the end.: *

NBC Nightly News (5/16/12) reported that a new study suggests that “coffee drinkers are slightly more likely to live longer than non-coffee drinkers.”

The Los Angeles Times (5/17/12) reports that for the study, published in the New England Journal of Medicine, “the National Cancer Institute researchers turned to data on 402,260 adults who were between the ages of 50 and 71 when they joined the NIH-AARP Diet and Health Study in 1995 and 1996.

The volunteers were followed through December 2008 or until they died — whichever came first.” The researchers found that, “compared with men who didn’t drink any coffee at all, those who drank just one cup per day had a 6% lower risk of death during the course of the study; those who drank two to three cups per day had a 10% lower risk, and those who had four to five cups had a 12% lower risk.”

Blogfinger Medical Commentary   by Paul Goldfinger, MD, FACC:

This is what we have to say about coffee in our book  “Prevention Does Work:  A Guide to a Healthy Heart” by Eileen and Paul Goldfinger, published 2011, prior to this coffee study:

“Coffee drinking confers no protection (against heart disease,) and some studies in the past have suggested an increased risk with coffee. If coffee is boiled, as in Europe, it can raise cholesterol levels, but if filtered, as in the U.S., it does not. In addition, some studies suggest a health benefit of coffee in lowering the risk of gall bladder disease and colon cancer. A recent trial suggested that coffee can protect against Alzheimer’s disease.

Some individuals are sensitive to the caffeine in coffee and can experience heart palpitations, anxiety and insomnia. It is not true that all heart patients need to eliminate caffeine, but you should check with your doctor. Watch for hidden sources of caffeine such as colas and dark chocolate.  One cup of tea has 50 mg., while coffee (brewed) has 135 mg of caffeine per 8 oz. cup. Colas contain 37-45 mg.in 12 oz, while dark chocolate has 30 mg.  in a 1 1/2 oz  bar.”

The trial described above is almost amusing since the relationship between coffee and dying in this study  is a happy one for those of us who like coffee, but it doesn’t give a clue as to how the relationship works.  Research trials in the past have been contradictory in terms of coffee as a risk factor for coronary heart disease.  In one trial, they postulated that the milk we put in coffee accounts for an increased risk. I’ve always been suspicious of that conclusion because the milk we use in coffee doesn’t amount to much.

Skim milk is awful in coffee, and half ‘n half seems to me to be a scary item.  Coffeemate contains high fructose corn syrup.  My own approach is to use skim- plus in my coffee  (that is skim milk with extra milk solids, so it is creamy, but is non-fat and has calcium and protein—a pretty darn good product in my anecdotal opinion).  But if I’m at Wegmans and get coffee, they don’t offer skim-plus, so I use whole milk because I can’t believe that the one ounce of milk will hurt me.

So, now that this New England Journal of Medicine study has been hyped by  the media, what have we learned?  My conclusion is to drink coffee, as long as you know about the addictive and cardio-stimulatory  potential of caffeine, and don’t worry about coffee as a risk factor for heart attacks.

Yet we all need something to worry about, so put coffee drinking on the back burner and worry instead about obesity, smoking, high blood pressure, diabetes, family history, hypertension, lack of exercise, stress, and diet.

And speaking of the latter, if you can, with your coffee, try to avoid the “and” which often accompanies the Joe.  If you have to fear your food, forget worrying about coffee and instead try being scared to death of Dunkin Donuts, fast food, cheese danish, cream puffs, twinkies, fudge cake, etc etc.  Avoid sugars of all types, bad fats, processed foods, excess calories and big portions.  Have a cucumber with your morning joe and eat more fruit and oatmeal. Then walk around the block.

OK, now if I can only follow my own advice

* Editor”s Note:   This coffee article was originally posted on BF in 2012. Now, in 2015, a new study from the National Institutes of Health shows that patients with stomach cancer experience reduced mortality rates and lowered recurrent cancer with coffee drinking.  The study was reported in the Journal of Clinical Oncology and studied 1,000 cancer patients.  The benefit was with caffeinated coffee, over 4 cups per day.  The research on coffee has also shown reduced risk of Parkinsonism, type II diabetes, and some cancers.  (August, 2015)

Here is a 2015 link:   www.nbcnews.com/health/cancer/coffee-aids-colon-cancer-recovery-study-finds-n411326

FRANK SINATRA    “Coffee Song.”

Read Full Post »


Read Full Post »

Jersey Shore University Medical Center is the flagship hospital of Meridian Health. Internet photo

Jersey Shore University Medical Center is the flagship hospital of Meridian Health. Internet photo

Hackensack University Medical Center. Internet photo

Hackensack University Medical Center. Internet photo. There is no sign of a university medical school  near either of these hospitals.


By Paul Goldfinger, MD.  Editor @Blogfinger.net

According to a report in today’s Asbury Park Press, this merger of two large healthcare systems is being done because of “financial pressures” on both systems due to the Affordable Care Act, “better known as Obamacare.” It will result in the largest such system in New Jersey.

This is just part of a frenzied re-shuffling of the healthcare deck which we are experiencing all around us. Hospital mergers like this have been occurring over the last ten years, but they have been accelerating due to pressures resulting from the ACA.

For example, on the physician side, we have seen most of the oncologists in New Jersey joining together and then merging with similar groups in nearby states. All of this is part of a power struggle for health providers to stay afloat and make money. As far as hospitals are concerned, they are trying to become huge corporate players by swallowing up their neighbor hospitals and maneuvering private practice doctors into becoming employees. In addition they are becoming like Amazon.com, trying to be the providers for everybody for everything, including all sorts of outpatient services like imaging centers, physical therapy facilities, surgical centers, and even nursing homes and insurance plans.

The result of such consolidations might raise the cost of healthcare, even though Meridian-Hackensack claims that they will lower the costs, as promised by the ACA. The insurance industry is less sanguine about this point. Wardell Sanders, who is president of an insurance trade group said, “Providers and hospital consolidations are often sold as measures to increase ‘efficiency’, but ironically they often result in higher prices for employers and individuals as efficiencies can be overshadowed by higher charges that larger health care systems often leverage in negotiations.”*

In plain English, your insurance premiums will probably go up, sooner or later.  (Note: For the next few years, the Federal Government is subsidizing insurance companies to keep them afloat, but when those subsidies end in 2017, the cost of insurance will go up more, even as they are already going up for some now.)

You will be told that these consolidations are about quality care, but I seriously doubt that, having experienced a hospital merger in Morris County first hand in the late 1990’s. In this  Meridian-Hackensack instance there is minimal talk about quality, with some vague references to prevention as a way to reduce costs. I am very skeptical about that point, and on Blogfinger, we have been focusing on quality concerns since the ACA appeared on the scene.

The first thing that happens when hospitals merge is that employees are fired in large numbers to save money, especially at the hospitals that are deemed expendible after a merger. This is accomplished by consolidating services, such as neurosurgery (ie “neurosciences services”) which might, for example, wind up in Hackensack. Next, once they have bought up rival hospitals, they may downsize them and then close them, deeming them to be useless (a self-fulfilling prophecy) and thus accessing the patient base of those hospitals.

Note that the discussions about this merger, as reported, do not include the words “regional healthcare planning,  patients’ needs, or patients’ freedom of choice.”

Presumably these two players will divide up the categories of care and then establish “centers of excellence” in one area or the other. This happened when Mt. Sinai in New York merged with NYU, but the whole thing fell apart over turf wars.

There is a giant snowball rolling down hill in healthcare, and patients should keep their eye on that ball, focusing on cost and quality.  The ACA horror and success stories will be evident as time goes by; we don’t know how the scales will tip.  Meanwhile, we are in the beginning of first inning of a long game ahead.


* Article from NJ Spotlight:    Merger report on NJSpotlight.com

AL JOLSON  with a song that might apply to how the patients view this situation.

Read Full Post »


By Paul Goldfinger, MD, Editor@Blogfinger

Last week we posted an article on Blogfinger that looked at the coercive effects of financial incentives in healthcare. We talked about ethics among doctors and we printed a letter to the editor from a physician who sent it to the New York Times.  That doctor bemoaned the compromise of traditional medical ethics while doctors get caught up in the pursuit of profits.  A Blogfinger Medical Commentary accompanies that post.   The link to that BF article is below.

Part 1 of BF healthcare business for doctors

Today the conversation in the Times continued as some physicians and others concluded that capitalism was not a good way to provide healthcare because of the profit incentives which ensue from  large corporations which have been taking over healthcare in this country.  In the process, many doctors have become employees and have to function according to the mandates of bottom-line-oriented executives.

Below is a link to today’s Times article, kindly provided by one of our FOB’s  (friends of Blogfinger) named Radar.

Medicine as a business NY Times Feb 9

Blogfinger Medical Commentary  Part II on this subject by Paul Goldfinger, MD, FACC:

I am frustrated, as are many doctors, by how the current economic system which drives healthcare creates  an environment for fraud, waste and abuse. To some physicians it seems that healthcare is a right which doesn’t lend itself to a capitalistic economic system.  (see today’s  NYT discussions linked above)

Our current healthcare is tarnished by out of control costs, corruptive fee- for-service reimbursement for doctors, and bottom-line oriented corporate management.   The costs are driven up by super expensive device manufacturers and pharmaceutical companies which have contributed to an unaffordable situation.

But I hasten to add that our current capitalistic system has produced the highest quality in providers, medical education, innovators, and creators of  extraordinary pharmaceuticals, high-tech diagnostic tests , and bioengineered/genetically driven advances of all sorts which promise a whole new future in medicine for this country and the world.

Other countries that have socialistic single payer  systems may be spending less, but they are not the innovators, and their quality and access cannot compare to ours. They look to America for the new advances.

Finally I am especially leary of Obamacare because, so far, it is overwhelmingly about cost and insurance, with little apparent concerns about quality.    As the ACA, with its mountains of regulations and restrictions , kicks in, Americans will, in my opinion,  become furious over access issues,  expensive premiums, and compromise of quality.

There is a chance that we will wind up with a single payer socialistic system.   Perhaps a compromise healthcare economy can be worked out over time with the government providing infrastructure, universal coverage, and regulation, but keeping physicians in charge of patient care.

In  Israel they have socialized medicine, but their medical care is excellent, and their high tech companies are world leaders and profitable. Similarly here there will have to be room for traditional American incentivization if we are to continue our successes while we fix the problems.

Read Full Post »


This letter to the editor appeared in the New York Times on February 5, 2014  from a physician who is concerned about the loss of traditional medical practice ethics:

To the Editor:

Recent accusations against the for-profit hospital chain Health Management Associates (“Hospital Chain Said to Scheme to Inflate Bills,” front page, Jan. 24), including that it put pressure on doctors to admit patients to increase profits, demonstrate the destructive power of the corporatization of medicine on the practice of medicine. The ethical base is lost when businesspeople take over and destroy the traditions of medical practice. Hospital Corporation of America, the nation’s largest for-profit hospital chain, is under investigation for similar practices.

Leaders of corporate America care little about the credo that established medicine as a noble profession, operated not for profitability but for the good of the patients. Sadly, doctors within the corporate system who have opposed fraudulent and illegal practices designed to maximize profitability are punished and terminated. Meanwhile, the white-collar criminal behavior of corporate executives is not adequately punished.

Such practices have a corrosive effect on independent doctors as well. This leads many to game the system and find loopholes to maximize profits. Costs soar. Hospitals and medical schools are often complicit.

Many decent doctors deplore the changes in health care delivery systems that foster such abuses. But I find it hard to be heard when I speak of accountability. I call on our current and next generation of medical school graduates to have the vision and courage to take back the leadership of medicine and restore its right to be considered a noble profession.


Naples, Fla., Feb. 3, 2014

The writer was a clinical professor of psychiatry at Tufts University School of Medicine.

Blogfinger Medical Commentary.  By Paul Goldfinger, MD , FACC

I think we must agree that medicine, a “noble profession,” has not been totally squeaky-clean when it comes to putting financial gain ahead of the best interests of patients. But Dr Corwin is certainly correct when he claims that the medical profession,  for the most part,  has lived up to its credo to always put the best interests of patients first.

Of course there are exceptions, but somehow, without an actual ruling body, doctors have usually done what’s right, and it is a source of pride to those of us who are physicians that we adhere to long-standing traditions regarding ethics, and most doctors can be trusted to honor their traditional priorities.

But, in my experience, financial conflicts of interest due to the fee-for-service system cause an ethical tug of war for some doctors, and such ethical failings have been going on for a long time including fee splitting which I saw when I first entered private practice.

Insurance companies are part of the problem in the other direction because they make more money by trying to withhold care. And  patients are also sometimes complicit because they don’t worry about such “abuses” as long as they are not paying directly.

Dr. Corwin is correct when he puts his finger on recent corporate practices that attempt to require doctors to churn services such as when employee-physicians are pressured to admit more patients just to increase the numbers. If healthcare allocation decisions are put into the hands of bureaucrats or corporate managers, the financial bottom line will be the guiding touchstone for practice policies.

Whatever ethical shortcomings might exist among doctors, they can be dealt with in a new healthcare system, but, as I have repeatedly said, doctors need to be in charge of patient-care decisions.

Read Full Post »


By Paul Goldfinger, MD, FACC

The silent killer:  Prevention doctors use this term to stress the fact that you could have high blood pressure without having symptoms  that might suggest a problem. Untreated high blood pressure can cause stroke, heart attacks, rhythm issues like atrial fibrillation, or congestive heart failure. That is why blood pressures are often checked on all comers at health fairs, drug stores, doctor offices  (even if it is a urologist) and other venues. 

Home devices:  I believe that every hypertensive patient should check his blood pressure readings at home.  All you really need is a simple home device which runs on batteries and is usually accurate. They sell them at most drug stores.   But you have to pay attention to the technique of placing the cuff. 

I don’t trust the ones that take a reading from your finger.  Write down your result, indicate the time and make a note if there are special circumstances  (such as being stressed or having just run up the stairs.)  Because of some anxiety associated with taking your own pressure reading, I recommend ignoring the first reading, waiting 1 or 2 minutes and then repeat.

Cuff size:  The cuff that goes around the upper arm should be placed carefully according to the directions,  and the size of the cuff needs to be correct for the size of the arm in order to get an accurate reading. If you are buying a home BP device, ask the pharmacist if the cuff is correct for you.  Sometimes a large cuff has to be special ordered.  For very obese patients, a thigh cuff may be needed—i.e. a cuff that would ordinarily be used to measure pressures in the legs. 

Echocardiograms:  Why should a doctor order this ultrasound procedure on patients with hypertension?  Uncontrolled hypertension causes the heart to work harder against an elevated pressure. That stresses the heart, and the heart muscle can thicken.  The echo measures cardiac wall muscle  thickness. A stressed heart can get weak and begin to enlarge.  The echo measures the size of the heart and the strength of contraction of the main pumping chamber–the left ventricle.  The test also assesses valve function. The “echo” is a very useful noninvasive test for following patients with hypertension.

Weight loss as therapy.  Even losing as little as 10 pounds can result in an improved blood pressure reading.  If you lose weight, you might be able to reduce the dose of your meds or avoid meds altogether.

Tailored therapy A doctor treating a patient with hypertension has to choose from a large list of drugs. There are variety of ways that anti-hypertension drugs work, so sometimes a drug is chosen for a specific reason. For example, if someone has a kidney problem , the doctor might choose an ACE inhibitor for its renal protective properties.  If a patient is young and has elevated blood pressure due to high adrenaline effects, then a beta blocker would be a good choice.

Dizziness from BP drugs  I called a friend, and when he picked up the phone he said, “I stood up and got dizzy.” He is hypertensive and takes a BP medication. I asked him if he ever told his doctor about his symptom and if his doctor ever took his BP standing. He said no to both.

One of the side effects of anti-hypertensive drugs is orthostatic hypotension, which means that the BP drops excessively when standing, often resulting in dizziness or even fainting.  Many of these drugs work by opening (dilating) blood vessels, but an exaggerated effect can cause the BP to drop excessively thus reducing blood flow to the brain.

The doctor ought to check the BP standing when evaluating anyone on such drugs, and the standing BP should be measured immediately and then after standing for a few minutes.

Mixing Viagra with your BP meds.  Viagra dilates blood vessels as do some BP drugs, and although it works somewhat differently than your BP meds, the combination of Viagra with a vasodilator BP drug may cause a problem such as dizziness due to low blood pressure. If you are on such BP meds, you should speak with your doctor about a low Viagra dose, at least to start. The last thing you want is to be in a romantic situation and then pass out on the floor. 

Should “White-coat hypertension (WCH)” be treated?  There are quite a few people whose BP is high in the doctors office but normal at home. The diagnosis is made by doing home BP readings or by 24-hour ambulatory BP recordings.  Medicare will pay for the latter test when a doctor needs to find out if his patient has WCH.

Once the diagnosis is made, should the doctor treat it?  Most experts say no, but there are some studies that say “maybe.” At the very least, patients with WCH can evolve into full-blown hypertension over time, so ongoing surveillance is important.

There are many issues that we are not covering today, and perhaps we will return to some of those another time.  Meanwhile, more than 60% of you will develop hypertension if you reach the Medicare years, so it is an important subject for discussion at the Blogfinger School of Medicine and Health Sciences based in Ocean Grove, New Jersey and at the Ocean Township Wegmans.

So, for now, our hypertension series is concluded, and this doctor’s office is closed. If you have a true medical emergency call 911 and hope that your insurance policy is still in effect.

Read Full Post »


By Paul Goldfinger, MD, FACC    Editor@Blogfinger

As many of you know, my main concern regarding Obamacare relates to how it will affect quality of care. But all we hear is about insurance and economics. But even with that, we can begin to see the effects on quality, because some people will be left naked on Jan 1 when they no longer have coverage. Obviously, if you don’t have health insurance, the quality of your care will be reduced.  But I am certain, as you know, that quality will be negatively impacted in many ways and I recently reported on the situation with practice guidelines potentially  interfering with the doctor-patient relationship.

However, on Jan 1, as people actually seek care under the ACA, I suspect we will hear many horror stories having to do with the deterioration of quality care. In today’s Wall Street Journal we find an opinion piece by Marc Siegel, MD, and Professor of Medicine  at the NYU School of Medicine. Dr. Siegel says he has awakened “to the harsh realities of our medical future.”  His piece rambles a bit, but you can see from his observations that you don’t need a weatherman to tell you which way the wind is blowing.  Here is Dr. Siegel’s “The Death of the Bedside Manner”     *Wall Street Journal, Dec. 27, 2013.

WSJ on Obamacare


Read Full Post »


Abbott posted this new topic:

“Medicare is not a good  analogy for the ACA.   Medicare is funded through payroll taxes (all pay the same tax rate).  Individuals are not required to participate in Medicare.  Medicare does not seek to massively subsidize one part of the population at the expense of another (although they have started down that road with premiums adjusted for income to a limited degree).   Medicare does not have restrictive networks of hospitals and physicians.  

“Said another way, the reason the majority of Americans are opposed to the ACA is that it forces people to buy something the may not want, it forces them (in many ways) to subsidize other Americans to buy something, and it is disrupting a healthcare system that works well for a majority of Americans.  

“Let’s face it — probably the only people who really support the ACA are the folks who want to be subsidized (financially and/or by spreading their bad risk).”

Blogfinger Medical Commentary:  By Paul Goldfinger, MD, FACC

Prior to the passage of the ACA,   80% of Americans said that they were satisfied with their health insurance and their doctors.  The ACA bill was sold to the public as being about providing coverage for the other 20% .

Some  parts of the plan were intentionally not revealed, leaving most Americans to believe that the ACA would not impact them.  This is lying by omission.  Some believe that the ACA was passed under false pretenses.

Abbott also mentions  doctor and  hospital networks . Prior to the ACA, most insurance plans that were considered to be good plans allowed the policy holders to see any doctor and to go to any hospital.  That was the norm and was true for Medicare and Medicaid as well.  This was one reason why many seniors preferred regular Medicare compared to the more restrictive Medicare Advantage plans. Most people still prefer  freedom of choice.

But ACA-approved insurance plans all seem to include networks of hospitals and doctors.  This will produce a big change in how medicine will be practiced, and there wasn’t a mention of it when the ACA was explained to the public before it was passed.  If any of you have found Obamacare plans that give free choice, please let us know.

Interestingly, Dr.  Ezekiel Emmanuel, an architect of the ACA,  said on TV last Sunday that you can have your usual doctor, but you may need to buy a more expensive plan that has your doctor in-network.  To his way of thinking, there was no lie when we were told that we could retain our doctor.

Also, every ACA plan seems to have significant deductibles and copays, and the lower the premiums, the larger the out of pocket costs. Many current pre-ACA plans  do not have copays or deductibles.  Some, however, may have caps on spending, which the ACA plans do not,  and policy holders can be balance billed by providers unless the doctors are “in-network.”  

Abbott makes another point when she says that Obamacare will “disrupt” our current healthcare system.  Some say that Obamacare is not about the delivery of  healthcare, but rather is about insurance reform. However, there is no doubt but that the ACA will change the way medicine is practiced in a multiple ways including enforceable practice guidelines, rationing of care, restricted physician networks, etc. The actual enforcers of practice changes will often be the insurance companies who will be trying to lower costs and follow ACA rules.

Read Full Post »


This topic is suggested by David Lurie of Ocean Grove who has included a link to the New York Times, December 9, 2013 issue. The paragraph below is written by him:

“Worth reading. Here are some examples of the actual people who are being helped, and who have been paying huge prices for our current system of providing (or not providing) care.  I  found telling the example of immigrants from China who – as children – had to return there for medical treatment and pharmaceuticals.  The cancer patient who was skimping on his chemo was more than a bit disturbing as well.  These realities, it seems to me, need to be reckoned with by anyone who want to nullify the ACA.”

Here is the link from today’s NY Times.

Amid the Uproar Over the Health Law, Voices of Quiet Optimism and Relief 

Blogfinger Medical Commentary:   By Paul Goldfinger, MD, FACC

We already know about some positive results that have occurred with Obamacare, including  the elimination of pre-existing illness restrictions by insurance companies, allowing young people to stay on their parents’ plan and the removal of dollar caps from health insurance plans.

But besides that, at this point, we have mostly promises which include providing coverage to over 30 million people. However we know that promises don’t count—only results–because of the broken promises regarding keeping your insurance and your doctors.

The New York Times article linked below by David Lurie is inspiring, and we all welcome relief for those in need, but putting out anecdotes like this will convince only the naive that the new healthcare system will make our country healthier.

We need to wait until  at least 2014 to learn how well the ACA is working in terms of the practice of medicine. I have been repeating that mantra and I will look forward to seeing documentation of success in the form of numbers and not anecdotes. If Obamacare delivers on its promises, then we all can jump on board and be happy.  But if it fails, then we will need to reinvent healthcare in the US.

Read Full Post »

Older Posts »

%d bloggers like this: