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Once the patient has been informed of available therapies and has discussed these options with his/her physician buy cheap kamagra, an informed decision can be made buy kamagra us. Clinician input based on experience with both conservative management and surgical skills increases the probability of identifying patients who will benefit from specific treatment options discount kamagra 50mg otc. Studies of European communities report comparable values ranging from 6 to 1-4 18 ruptures per 100 generic kamagra 100 mg without a prescription,000 people. Time away from work may impact the 5 patient financially and limiting activity may impact the patient’s health. Some studies have shown 3 that ruptured Achilles tendons have occult degeneration. The injury often results in the patient’s inability to walk or perform their regular activities of daily living. Patients face possible deformity if the tendon does not heal correctly and a substantial recovery period. Possible complications associated with Achilles tendon rupture include rerupture and, in cases of surgical repair, infection. Long term results were often not available and complications varied by study (frequently they were not reported) in the literature available for this guideline. Most treatments are associated with some known risks, especially invasive and operative treatments. We developed systematic reviews for this guideline because these reviews employ specific processes designed to minimize bias in the 6, 7 selection, summary, and analysis of this literature. In referring to bias, we explicitly mean both the biases that can arise from financial conflicts of interest and biases that can arise from intellectual conflicts if interest. This section of the present document describes how we conducted our systematic reviews and how the guideline was developed. Accordingly, in this section we describe our strategies for finding relevant literature, our criteria for selecting articles to include in this guideline, how we extracted data, how we appraised and graded the evidence, our methods of statistical analysis, and the review and approval steps this guideline went through. Elsewhere in this document, we provide extensive documentation so that interested readers can assure themselves that we attempted to combat bias wherever possible. The work group met again on July 31 and August 1, 2009 to write and vote on the final recommendations and rationales for each recommendation. These recommendations specify [what] should be done in [whom], [when], [where], and [how often or how long]. They function as questions for the systematic review that underpins each preliminary recommendation, and they do not function as final recommendations or conclusions. Once established, these a priori preliminary recommendations cannot be modified until the final work group meeting. The a priori and inviolate nature of the preliminary recommendations combats bias by preventing a “change in course” if a systematic review yields results that are not to someone’s liking. The results of each systematic review are presented and discussed at the final work group meeting. At this time the preliminary recommendations are modified in response to the evidence in the systematic review. These criteria are our “rules of evidence” and articles that do not meet them are, for the purposes of this guideline, not evidence. To be included in our systematic reviews (and hence, in this guideline) an article had to be a report of a study that: • Evaluated a treatment for acute Achilles tendon rupture. Acute Achilles tendon ruptures are defined as a rupture treated within zero to six weeks post injury. We included surrogate outcomes only when patient-oriented outcomes were not available. Surrogate outcomes are laboratory or other measurements that are used as 9 substitutes for how a patient feels, functions, or survives. We only included data for an outcome if ≥ 50% of the patients were followed for that outcome. For example, some studies report short-term outcomes data on nearly all enrolled patients, and report longer-term data on less than half of the enrolled patients. Additionally, we downgraded the Level of Evidence by one in instances where 50% to ≤80% of patients were followed. We only included data for outcomes reporting the average length of time to return to an activity if >80 % of the patients were included in the calculation. For example, some studies report the mean time for return to work as 6 weeks but are only including data for patients who have actually returned to work and are ignoring patients who are unable to return. Using comprehensive literature searches ensures that the evidence we considered for this guideline is not biased for (or against) any particular point of view. Strategies for searching electronic databases were constructed by a Medical Librarian and reviewed by the work group. All searches of electronic databases were supplemented with manual screening of bibliographies of all retrieved publications. We also searched the bibliographies of recent systematic reviews and other review articles for potentially relevant citations. Finally, a list of potentially relevant studies not identified by our searches was provided by the work group members. A study attrition diagram (provided in Appendix V) documents, for each recommendation, the number of articles we identified, where we identified these articles, the number of articles we included, and the number of articles we excluded. The use of extracted data in our systematic reviews is another of our methods to combat bias. It ensures that our results are based on the numerical results reported in published articles and not on the authors’ conclusions in the “Discussion Sections” of their articles. We assessed the quality of the evidence for each outcome at each time point reported in a study. We evaluated quality on a per outcome basis rather than a per study basis because quality is not necessarily the same for all outcomes and all follow-up times reported in a study. For example, a study might report results immediately after patients received a given treatment and after some period of time has passed. Often, nearly all enrolled patients contribute data at early follow-up times but, at much later follow-up times, only a few patients may contribute data. The fact that we would assign a higher quality score to the earlier results reflects this difference in confidence. First, we assigned a Level of Evidence to all results reported in a study based solely on that study’s design. Assigning a Level of Evidence on the basis of study design plus other quality characteristics ties the Levels of Evidence we report more closely to quality than Levels of Evidence based only on study design. Because we tie quality to Levels of Evidence, we are able to characterize the confidence one can have in their results. Unlike Levels of Evidence (which apply only to a given result at a given follow-up time in a given study) strength of the recommendation takes into account the quality, quantity, and applicability of the available evidence. Strength of the recommendation also takes into account the trade-off between the benefits and harms of a treatment or diagnostic procedure, and the magnitude of a treatment’s effect. The strength of a recommendation expresses the degree of confidence one can have in a recommendation. As such, the strength expresses how possible it is that a recommendation will be overturned by future evidence. It is very difficult for future evidence to overturn a recommendation that is based on many high quality randomized controlled trials that show a large effect. It is much more likely that future evidence will overturn recommendations derived from a few small case series. Consequently, recommendations based on the former kind of evidence are rated as “strong” and recommendations based on the latter kind of evidence are given strength of recommendation of “limited”. The final strength of the recommendation is assigned by the physician work group, which modifies the preliminary strength rating on 7 v1. A Strong recommendation means that the benefits of the recommended approach clearly exceed the potential harm (or that the potential harm clearly exceeds the benefits in the case of a strong negative recommendation), and that the strength of the supporting evidence is high. Moderate Evidence from two or more “Moderate” strength studies with Practitioners should generally follow a consistent findings, or evidence from a single “High” quality Moderate recommendation but remain alert to study for recommending for or against the intervention. Limited Evidence from two or more “Low” strength studies with Practitioners should be cautious in deciding consistent findings, or evidence from a single Moderate whether to follow a recommendation classified quality study recommending for or against the intervention or as Limited, and should exercise judgment and diagnostic.

The request note to the laboratory must therefore state the request for: Borrelia serology inc buy kamagra 100 mg without prescription. Borrelia Antigen description of Specificity Remarks proteinan- the antibodies tigen p14 buy kamagra master card,18 high Mainly in cases of B generic 100mg kamagra fast delivery. There may be a disease requiring treatment even without the detection of antibodies order kamagra 50 mg on-line. With a single serological test it is not possible to decide whether this infection is active or latent; at best this can be decided by the attending physician on the 6 basis of its clinical development. It is not within the remit of a laboratory physician to evalu- ate a positive finding as a “serological relic” i. If acute neurobor- reliosis is suspected, the treatment should not be made dependent on the laboratory re- (123) sults. The following arguments support the use of cellular immunological methods in the labora- tory diagnosis of Lyme borreliosis: 1. The sensitivity of the methods for the direct identification of Borrelia is technically inadequate at present for daily practice. On the other hand, a negative serological finding does not rule it out, especially when there are early manifesta- tions of Lyme borreliosis, see 2. Certain laboratories offer different methods for the detection of Borrelia-specific activation of T lymphocytes, such as the EliSpot-Test-Borrelia®, for example, to answer these questions. In these methods, the induction of cytokine synthesis is measured at the cellular level. In the event of professional trade association proceedings or legal disputes with insurance companies, it may be worthwhile as a supple- mentary test in an individual case, because it can sometimes reveal considerable cerebral perfusion disturbance in Lyme borreliosis. By modulating the immune system, co-infections aggravate the severity of disease states and are regarded as a significant reason for resistance to ther- (22/32/43/53/73/87/89/107/116/117/143/146/148/152/158/162) apy. On the other hand, other authors (3/17) describe cases of transmission by ticks and other arthropods. Moreover, Bartonella henselae, like Borrelia burgdorferi, is able to provoke a multi-organ (132) disease. The considerable shortcomings in the scientific- clinical analysis are reflected in therapeutic guidelines, which are severely limited in the reli- ability of their recommendations and in their evidence base in the international litera- (159) ture, and they do not meet the requirements from the medical and health-policy aspects. With regard to antibiotic treatment, problems also arise with Borrelia due to natural or acquired resistance. The causative agent of Lyme borreliosis can evade the immune system (7/74) by what are known as “escape mechanisms”. In the chronic forms, it is significantly higher (30/31/52/55/74/99/121) at up to 50%. Even earlier studies referred to the problem area of chronic (31/55/59/61/62/65/92/94/121/138) Lyme borreliosis and the limits of its susceptibility to treatment. In all these studies, the duration of treatment was generally limited to a maximum of four weeks. Considerable therapeutic failure rates occurred under these conditions, even with (78/82/90) repeated courses of treatment. The duration of treatment is of decisive importance for the success of antibiotic treatment. There are now a few studies available which provide evidence of the positive effect and the (25/26/27/30/36/44/46/51/52/81/144) safety of long-term antibiotic therapy. The limited effect of antibiotic treatment is documented in numerous studies: Pathogens were cultured even after supposedly highly effective antibiotic ther- (63/74/81/96/119/120/122/139/147) apy. For example, Borrelia were isolated from the skin after multi- (40/61/76/81/122/147) ple courses of antibiotic treatment (ceftriaxone, doxycycline, cefotaxime). A discrepancy was also found between the antibiotic sensitivity of Borrelia in vitro versus in (74) vivo. Moreover, additional factors are involved in vivo which lie in the capability of Borre- (60/83/85/86/120) lia to evade the immune system, specifically under the influence of various (80) antibiotics. Hypothetically, the persistence of Borrelia is attributed to its residency within the cell and to the development of biologically less active permanent forms (sphaeroplasts, encystment) (19/85/86/94/120) among other things. In addition, Borrelia was also shown to develop biofilms with the effect of resisting complement and typical shedding (casting off antibodies from the (83/85/86) surface of the bacterium). The ability of the pathogen to down-regulate proteins (pore-forming protein) might also diminish the (34/74/84) antibiotic effect. There are four randomised studies relating to the therapy of chronic Lyme borrelio- (44/78/82/90) sis, in which different antibiotics were compared when used in the antibiotic treat- ment of encephalopathy. It was shown in these studies that the cephalosporins were supe- (31/62/94/96) rior to penicillin. Doxycycline in its customary dosage resulted in only relatively low serum levels and tissue concentrations, whereas the concentrations in the case of the cephalosporins were markedly higher, i. Of the available antibiotics, tetracyclines, macrolides and betalactams have proved effective in the treatment of Lyme borreliosis. The efficacy of other antibiotics, especially the (20/74/160) carbapenems, telithromycin and tigecycline, is based on in vitro studies. There are (64) no clinical studies except for imipenem, which was given a favourable clinical assessment. The efficiency of a combined antibiotic therapy has not been scientifically attested to date; this form of treatment is based on microbiological findings and on empirical data that have not so far been systematically investigated. As table 5 shows, only the substances metronidazole and hydroxychloroquine have an effect (101) on encysted forms. Hydroxychloroquine assists the action of macrolides and possibly also that of the tetracyclines. This is particu- larly applicable in the case of children and patients with above or below normal weight. Some physicians of the German Borreliosis Society are critical of the use of 3rd generation cephalosporins or of penicillins alone in Lyme borreliosis, because they may possibly favour (101/120) the intracellular residency of Borrelia and its encystment. If ceftriaxone is used, a sonographic check every 3 weeks is necessary to rule out sludge for- mation in the gall bladder. Table 6: Antibiotic monotherapy of Lyme borreliosis In the early stage (localised) Doxycycline 400 mg daily (children of 9 years old and above) Azithromycin 500 mg daily on only 3 or 4 days/week Amoxicillin 3000-6000 mg/day (pregnant women, children) Cefuroxime axetil 2 × 500 mg daily Clarithromycin 500-1000 mg daily Duration dependent on clinical progress at least 4 weeks. In the early stage with dissemination and late stage Ceftriaxone 2 g daily Cefotaxime 2-3 x 4 g Minocycline 200 mg daily, introduced gradually Duration dependent on clinical progress. Corticosteroids should be adminis- tered parenterally only in an emergency, depending on the severity of the reaction. During long-term antibiotic treatment, probiotic treatment should be given to protect the in- testinal flora and to support the immune system (e. Several meta-analyses show that the prophylactic use of probiotics (13/24/28/38/102/127) lowers the risk of antibiotic-associated diarrhoea. The action of macrolides and possibly also of tetracyclines is intensified by the simultaneous administration of hydroxychloroquine, which, like metronidazole, acts on encysted forms of (36) Borrelia. If minocycline is not tolerated, it can be replaced with doxycycline or clarithromycin. Doxycycline and minocycline can be combined with azithromycin and hydroxychloroquine. To make it easier to identify drug intolerance, the treatment should not be started with the individual antibiotics given simultaneously. It is preferable to add the other antibiotics stag- gered over time, say at intervals of one to two weeks. Prevention involves the following factors: • exposure to ticks • protective clothing • repellents • examination of the skin after exposure • removal of ticks that have started feeding. Recurrence is treated again as necessary, but generally in cycles of shorter treatment times, e. With regard to the risk of exposure, it should be noted that ticks wait in grasses and under- growth up to a height of 120 cm above the ground. On contact, the ticks are brushed off the vegetation and can get to all parts of the body across the skin (beneath clothing). Ticks pre- fer moist and warm areas of skin, but a tick bite can basically occur on any part of the body.

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Improving compliance with therapeutic regimens in hypernsive patients in a community health cenr buy kamagra 50mg low price. Effects of weighloss and sodium reduction inrvention on blood pressure and hypernsion incidence in overweighpeople with high- normal blood pressure purchase kamagra once a day. Cost-lowering stragies used by medicare beneficiaries who exceed drug beneficaps and have a gap in drug coverage cheap kamagra 50 mg on line. Potilaiden nakemyksia kohonneen verenpaineen hoidosta � hoitomyontyvyyttako paranta- malla tuloksiin? Changes in the reasons for requiring out-of-hours medical care from a centralized primary care centre afr changing to a lissysm discount kamagra 50 mg visa. Prospective study on la consequences of subclical non-compliance with immunosuppressive therapy in renal transplanpatients. Social networks as predictors of ishemic heardisease, cancer, stroke and hypernsion: incidence, survival and mortality. Whahas been learned from electronic monitoring of compliance with antihypernsive medications? Self-initiad modification of hypernsion treatmenin response to perceived problems. A randomized controlled trial of an information booklefor hypernsive patients in general practice. Facts and fiction of poor compliance as a cause of inadequa blood pressure control: a sysmatic review. Effecof aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials. Tutkimuksemme tavoitena on selvittaa verenpainetaudin laakehoitoon liittyvia ongelmia laakkeen kayttajan nakokulmasta. Tutkimuksen tuloksia on tarkoitus hyodyntaa verenpainehoidon suunnitlussa ja laakitykseen liittyvassa neuvonnassa. Toivomme idan ystavallisesti vastaavan oheisiin kysymyksiin tarkasti ja huolellisesti seka palauttamaan kyselyn oheisessa kirjekuoressa (postimaksu on jo maksettu) mahdollisimman pian, mutta kuinkin viimeistaan kahden viikon kuluessa. Kaikki antamanne tiedokasillaan ehdottoman vaitiolovelvollisuuden pohjalta ja vastauksianne kaytaan vain tutkimuskayttoon. Oppaan ovakirjoittaneeSydantautiliiton asiantuntijalaakari Jyrki Olkinuora ja dosentti Timo Klaukka. Mikali haluaosallistua arvontaan tayttakaa oheinen erillinen arvontalomake ja palauttakaa myos se vastauskuoressa. Arvontalomakkeerollaan vastauslomakkeista valittomasti niiden saavuttua, eika henkilotietoja liita tutkimustietoihin missaan vaiheessa. Jos illa on kysyttavaa tutkimuksesta, voisoittaa professori Hannes Enlundille puh: 971-162 500 tai proviisoriopiskelija Erkki Jokisalolle puh 981-311 2019. Onko rveydentilanne nykyisin mieles- 2 kerran paivassa tai useammin tanne yleensa 3 muutaman kerran viikossa 4 muutaman kerran kuukaudessa 1 hyva 5 harvemmin 2 melko hyva 6 en kayta verenpainemittaria 3 kohtalainen 4 melko huono 5 huono 12. Ovatko kayttamanne verenpainelaakkeeaiheuttaneeille epamiellyttavia tunmuksia tai haittavaikutuksia? Haittavaikutus (laakkeen nimi) erittain epa- kohtalaisen hieman jokseenkin miellyttava epamiellyttava epamiellyttava harmiton 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 16. Onko idan ollupakko luopua jostakin mukavista asioista (esimerkiksi harrastuk- sista) verenpainetautinne vuoksi? Jos kaytaverenpainelaakkeita oman 3 usein mielenne mukaisesti, niin mitka seuraavista ovamielestanne tarkeimmasyysiihen 20. Aiheuttaako verenpainelaakkeen oton 6 laake jai uusimatta, jon en kayta sita sovittaminen paivarytmiin hankaluuksia 7 laakkeiden jatkuva nauttiminen ei ole (tyon, matkuslun tai muun sellaisen syyn 8 muu syy, mika? Ovatko verenpainelaakkeiden aiheut- tamakustannukseille taloudellisesti 1 ei 2 joskus 1 suuri rasi 3 usein 2 kohtalainen rasi 3 vahainen rasi 4 taysin merkitykseton rasi 29. Oletko mielestanne saanutarpeeksi tietoa verenpainelaakkeiden En Kylla En osaa sanoa annostuksesta. Osallistumme valtakunnalliseen Verenpainepotilaan hoito rveyskeskuksessa 1996 - 97 -tutkimukseen, johon meidan lisaksemme osallistuu 29 muuta rveyskeskusta eri puolilta Suomea. Jotta tutkimus meidan rveyskeskuksessamme onnistuisi hyvin, pyydan ita tayttamaan nama kyselylomakkeehuolellisesti. Tuodessanne kyselyn osa I:n hoitajan vastaanotolle, voiyhdessa taydentaa mahdollisesti puuttuvatiedoja hoitaja tayttaa lomakkeen viimeiselle sivulle laboratorio- yms. Sen sijaan rveyskeskuksemme saa paikkakuntamme kaikkien tutkittavien potilaiden vastausn keskiarvot. Naiden tulosn perusella voimme kiinnittaa huomiota rveyskeskuksemme verenpaineen hoidossa mahdollisesti ilmeneviin puutisiin ja parantaa nain potilaitmme hoidon laatua. Omalaboratorio- ja seurantakayntinne tuloksesaahoitajalta ja hoitavalta laakariltanne. Tullessanne hoitajan vastaanotolle, ottakaa mukaan kaikkien laakarin maaraamien ja nykyisin kayttamienne laakkeiden resepti(tai laakepurkit, mikali eloyda resepjanne). Tutkimuksen vastuulaakari (leima) Arvoisa potilas Verenpaineen hyva hoito on ensiarvoisen tarkeaa torjuttaessa sydan- ja verisuonitauja, erityisesti aivohalvauksia ja sepelvaltimotautia (sydaninfarkja). Tassa tutkimuksessa pyrimme saamaan mahdollisimman seikkaperaisen kuvan verenpaineen hoidon toutumisesta Suomessa. Antamanne tiedovoivaolla ratkaisevia pyrittaessa parantamaan verenpainepotilaan hoitoa maassamme. Luonnollisesti myos yliopistossa noudataan vastauksienne suhen ehdotonta vaitiolovelvollisuutta. VastausohjeeRengastakaa vastausvaihtoehdoista vain yksi, ellei kysymyksen ohjeissa ole muuta mainittu, esimerkiksi Hoitaako verenpainettanne paaasiassa 1 rveyskeskuslaakari 2 tyorveyslaakari rveyskeskuksessa 3 muu tyorveyslaakari 4 yksityislaakari 5 en ole laakarin hoidossa verenpaineeni vuoksi Avoimissa kysymyksissa kirjoittakaa vastaus sille varattuun tilaan. Esimerkiksi Ovatko talla hetkella kaytossanne olevaverenpainelaakkeeaiheuttaneeille mitaan haittavaikutuksia 1 ei 2 kylla, mika laake ja millaisia haittavaikutuksia? Esimerkiksi Taysin Jokseenkin Jokseenkin Taysin samaa samaa eri eri mielta mielta mielta mielta rveyskeskuksessa on liian vahan veren- paineen mittausaikoja. Mita verenpainelaakkeita kaytatalla 2 en hetkella (tarkistakaa nimeja annostukseb) yhden (saman) rveydenhoitajan luona? Kaytko verenpaineenne vuoksi Laake Haittavaikutus a) laakarissa 1 6 kertaa vuodessa tai useammin 2 4 - 5 kertaa vuodessa 3 2 - 3 kertaa vuodessa 4 kerran vuodessa 5 noin joka toinen vuosi 6 harvemmin 10. Onko laakari keskuslluidan kanssanne seuraavista verenpaineenne hoitoon liittyvista a) rveydenhoitajan luona asioista? Oletko hoitavan laakarinne kanssa Tupakoinnin lopettaminen 1 2 3 sopinuverenpainearvosta, johon idan Saannollinen liikunta 1 2 3 hoidossanne olisi pyrittava? Verenpainelaakkeiden 1 kylla on sovittu, tavoitena on paasta saannollinen kaytto 1 2 3 arvoon / mmHg 2 on puhuttu verenpaineen alentamisen Saannollisetarpeesta ilman tarkkaa rajaa verenpainekontrolli1 2 3 3 ei ole sovittu mitaan Suolan kayton vahentaminen 1 2 3 11. Oletko sopinuhoitavan laakarinne kanssa kanssanne seuraavista verenpaineenne idan tavoitena olevasta kolesroli- hoitoon liittyvista asioista? Kylla Ei Ei koske 1 kylla on keskusltu, tavoitena on minua kohdallani paasta lukemaan_____mmol/l Vaharasvainen ruoka 1 2 3 2 on puhuttu kolesrolin alentamisen Laihduttaminen 1 2 3 tarpeesta ilman tarkkaa tavoitta 3 ei ole keskusltu kolesrolin alentamisen Alkoholin kaytto 1 2 3 tarpeesta Tupakoinnin lopettaminen 1 2 3 Saannollinen liikunta 1 2 3 Verenpainelaakkeiden 17. Min hoidakorkeaa kolesrolianne saannollinen kaytto 1 2 3 (tassa voivalita useita kohtia)? Saannollise1 en minkaan verenpainekontrolli1 2 3 2 ruokavaliolla Suolan kayton 3 laakkeilla vahentaminen 1 2 3 4 muulla tavalla, milla? Kaytatko talla hetkella kolesrolia missa mittauksissa viimeksi kuluneen vuoden alentavia laakkeita? Oletko kayttanyviimeksi kuluneen vuoden (12 kk) aikana verenpainelaakkeita Laake Vahvuus (mg) Annostus vahemman kuin mita laakari on maarannyt? Mita ilman laakemaaraysta saatavia laakkeita vuoden (12 kk) aikana kolesrolia alentavia olekayttanyvahintaan kahdesti viimeksi laakkeita vahemman kuin mita laakari on kuluneen viikon (7 vrk) aikana? Ovatko laakkeiden kokonaiskustannukse(kaikkien laakkeiden kustannukset) vaikutta- neeviimeksi kuluneen vuoden (12 kk) aikana laakkeiden kayttoonne? Onko illa koskaan todettu tai hoidettu mitaan useita vaihtoehtoja) seuraavista sairauksista? Mita muita laakarin maaraamia laakkeita virtsatietulehduksia, munuaiskivi) kuin verenpainelaakkeeja kolesrolilaak- 13 kihti keeolekayttanyvahintaan kahdesti viimeksi kuluneen viikon (7 vrk) aikana? Tarkistakaa omasta Kela-kortistanne, mitka seuraavista erityiskorvattaviin laakkeisiin oikeuttavista numeroista ilta loytyvaja rengastakaa numerot. Kuinka monta vuotta yhensa olekayny2 en ole viimeksi kuluneen vuoden paatoimisesti koulua tai opiskellulamanne aikana enaa kayttanyalkoholia 3 kaytan alkoholia ja keskimaarainen aikana? Lakritsin syonti voi vaikuttaa veren- 7 ansiosidonnainen tyottomyyspaivaraha paineeseen.

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