Home » Sepsis: the killer you probably know almost nothing about

Comments

Sepsis: the killer you probably know almost nothing about — 62 Comments

  1. This is a very timely post for me. A month ago my mother spent a week in the hospital with sepsis. She had no symptoms of infection – no pain or fever at all. I spoke to her and she didn’t sound quite right so I asked my sister to check on her. My sister got there 10 minutes later to find her on the floor and incoherent. The same day a co-worker’s mother did the exact same thing. An uncle complaining of kidney stones but no symptoms of infection came close to death from sepsis. And I just spent Thanksgiving weekend at the out-of-town funeral of my 97-year old aunt who died from organ failure caused by sepsis. She too had no symptoms of infection.

    Thanks for this info, Neo.

  2. This is why my uncle, who was a doctor for many years, went on and on about avoiding surgery whenever possible. Elective surgery especially. He knew the risks of infection and sepsis.

  3. Two members of my family have experienced septic shock. One, a young, healthy, beloved woman, developed it in conjunction with meningococcemia and, just as Neo described, went from blooming health to death’s door in a few short hours. She survived – unscathed, thank Providence and modern medicine – only because she was taken to the emergency room early on and was already being cared for when her blood pressure collapsed. My mother, in her 80s, was less fortunate. She developed precisely the symptoms Neo described in her last paragraph, plus mental confusion, which turned out to be a rapid, insidious pneumonia and sepsis. She was hospitalized and pumped full of antibiotics, briefly rallied and seemed likely to recover, but then died of a stroke caused by an interaction among the illness, the medications she was given and her pre-existing medical conditions. In effect, the sepsis killed her.

    What I took from the two experiences: if you develop fever and other symptoms that may seem like an ordinary flu or virus but you feel worse than usual, if you’re feeling really awful, and especially if you’re experiencing any changed consciousness — get the heck to a doctor or an ER, fast. Better to waste some money and medical time on a minor illness than to be far from medical help if it’s sepsis or something like it – there’s just no time to be wrong.

  4. I had blood poisoning when I was in my twenties under circumstances very similar to Coolidge’s son. Luckily, I only had to spend a few days in the hospital being treated with antibiotics. Even though I was young and generally healthy, I might have died if it hadn’t been for antibiotics. Any puncture wound is a risk, so it’s important to take proper care of it.

  5. Robot shoots UV rays to kill bugs in hospitals at link below.

    And I would add, a Hillary Clinton regime kills innovations like this and in bio-tech. No doubt about it.

    http://www.xenex.com

  6. Mrs Whatsit:

    No, very little chance of that, although there was a period of time when I though she might be, because there was a little improvement.

  7. As a retired RN I practice immune system support. Take B vitamins, have your level of Vit D checked most Americans deficient. After its vitamin work is done , extra vit D acts like a natural steroid in the body & we know steroids suppress
    inflammation. Take your daily low dose Aspirin, again it s an
    Inflammation fighter!

  8. Baklava:

    The death rate among those who get severe sepsis is between 30% and 50%. If they have gone into kidney failure, the death rate is 75-80%.

  9. Timely post for me as well, and poignant: My retired former law partner (25 years together) attended a college football game at his Alma Mater on November 21 — thirteen days ago –then two days ago they admitted him to hospice care with sepsis.

    Diagnosis: Leukemia with pneumonia and now, sepsis as complications. No longer conscious and not expected to live past the weekend.

    I never got to say goodbye.

  10. K-E:

    Surgery is one way a person could get sepsis, but it’s by no means the only way and I don’t even think it’s the most common way. The most common way seems to be lung infection, particularly pneumonia.

  11. It is kind of amusing, medically, to read pieces like this one of Neo’s, when a medical issue is discovered and responded to with, dare I say it, startled agitation. Sepsis! It is a bad word in medicine. Has always been.

    There are some inescapable facts:
    1) We are not getting out of this life alive
    2) There are no magic answers. No sure things. Antibiotics, appropriately chosen and given in massive doses, are not certain to yield the desired result. We crave certainty in an uncertain world.

    It takes some getting used-to.

    I had as an intern, many years ago, a young previously healthy woman who’d come down with a beta-strep pneumonia (the same bug that causes the so very ordinary and mundane strep throat). We literally filled her with penicillin.
    And she died.
    Bothered me for a long time. Obviously, I have never forgotten; I can still see her. She should have lived, the penicillin should have done it. But she died.

    You get that today, you still can die.

  12. Frog:

    I’m so glad you are AMUSED by this, from your high perch on the medical hill.

    Nothing in my post could be construed to mean that I ever was surprised that there are no magic answers, or expect sure things.

    Just to spell it out for you, because obviously you fail to understand:

    Most people are not aware of the danger signs that they might have sepsis. Even I, a fairly knowledgeable person about medical facts, was unaware of the signs, how common it is, and in particular of how quickly it can kill even a fairly healthy person, who can go from walking around seemingly okay to at death’s door in just a few hours. This post is a way to make my readers aware of those danger signs in particular, letting them know that it could mean a matter of life and death to get to medical attention quickly.

    You, of course, don’t need this information. But perhaps you can stretch your mind to understand how the non-medical peons among us might be helped by it.

  13. Frog and others:

    By the way, a similar sort of disease process was publicized years ago by the death of Muppet inventor Jim Henson from toxic shock syndrome in 1990. I became aware of that particular disease at the time; in toxic shock syndrome, a toxin is released by the bacteria that leads to multiple organ collapse. But TSS is rare. Until recently, I was unaware that there was a much more common phenomenon that could similarly lead to multiple organ collapse and death rather quickly.

    Henson’s illness started with a cold or flu-ish symptoms that quickly led to pneumonia and TSS in an otherwise-healthy 53-year-old man.

  14. If you need to have surgery the Best surgical outcomes occur in patients who have the highest Vitamin
    D Level onboard.
    Pay attention too to adequate *Antioxidants*. These fight free radicals. Free radicals are *trouble makers* in the body.
    They occur secondary to our metabolic processes like eating,
    Growth & repair when you are sick more of them are produced. Vit C&E scavange free rads as does ( neo avert your eyes) GREEN TEA !!!!

  15. Neo,

    My mom nearly lost her leg after a cut on a hassick when she ran into it.

    The infection basically left her with a year’s worth of her leg recovering because it rotted from the inside so FAST!

    This post reminded me of that.

    My wife cut her foot on an ornament a few days ago and I’m immediately getting the Neosporin out and cleaning and bandaging.

  16. Neo misses my point. Which was about startled agitation as a response to a discovery
    It’s not about a view from a hill. It’s about the nature of a response..

  17. Frog:

    Nice try, but no, I did not miss your point.

    Maybe you are unaware of what you actually said and what it conveyed.

    I was addressing several of your points.

    The first was that you are amused. Unfunny:

    It is kind of amusing, medically, to read pieces like this one of Neo’s, when a medical issue is discovered and responded to with, dare I say it, startled agitation.

    The second and third were these:

    There are some inescapable facts:
    1) We are not getting out of this life alive
    2) There are no magic answers. No sure things.

    Put it all together and you get exactly what I was responding to: snide amusement at we non-medical peons who are so startled and agitated at learning about something like SEVERE sepsis, the details of which I was not aware of before (although you, as an MD, had heard about them long ago), and the symptoms of which I am trying to get out to a still-relatively-unaware public.

    My own “startled agitation” was about that seeming unawareness of most of the public, and the desire to get the word out in hopes that it could prevent something similar from killing as many people as it does. People who fall prey to sepsis and who were not already in the hospital often don’t realize what they are dealing with until they go into septic shock. The idea is to try to get earlier treatment prior to septic shock. This could help reduce the very high mortality with this illness.

    I find your reaction of amusement—even “medical amusement”—to be rather startling, as well.

  18. I know someone who died of septic shock. It was awful. He had been feeling sick and rundown for several weeks before he went to a doctor. I saw him a day or two before that and he looked abssolutely terrible. But he was young and healthy and didn’t realize how really bad he seemed, though everyone was worried about him. No cause that I am aware of was ever found. They did induce a coma to try to save his life.

  19. One more biggy newest antioxidant *star* is turmeric !!!
    This may mitigate Alzheimer’s !!!!
    India has worlds lowest Alzheimers rate. Turmeric comes from there, used in manydishes & even drunk as a tea!
    Theory is that it discourages brain plaque. Also has same effect as Cox2 inhibitors and NO side effects.
    Anecdotally have been using it months now & my memory
    has benefitted ! Sold on the stuff !!

  20. My wife died 11 years ago from this. Started out as abdominal pain.Was diagnosed as a small bowel obstruction. She crashed during surgery. Pressure from the obstruction forced bowel toxins thru a weak spot,flooding her abdominal cavity with toxic gunk. She was in shock lung, requiring a special jet ventilator. One by one her bodies systems failed in an inexorable cascade. After eight days of the most intense ICU care I’d ever seen, the machines were withdrawn.Everything hd been done;nothing worked. I’m a retired ICU RN, and she was a retired LPN, so wed both seen a lot. This was devastating beyond anything.

  21. Thank you so much for writing about this. I was totally unaware of sepsis until my best friend died 4 months ago from this.

    She was a vibrant, energetic mother of 4. Her husband took her to the hospital Friday night, thinking she had severe food poisoning. She was dead by Saturday morning.

    She is greatly missed by her family and her friends.

  22. I again want to express condolences to all who’ve lost someone from this devastating illness.

    I also am surprised that so many commenters have had personal experience with it, which drives home my point that it is a fairly common disease.

  23. I keep a children’s book called Great Men of Medicine on my bookshelf right above my computer. Published in 1961, it’s a group of short stories describing the men who fought the establishment and made the major advances in medicine which we now accept as “no big deal”.

    Ambrose Pare – sutering, 1537
    Edward Jenner – smallpox, 1796
    Rene Theophile Laenned – the science of diagnosis, 1819
    William Morton – anesthesia, 1844
    Louis Pasteur – bacteria, 1849
    Joseph Lister – antiseptic surgery, 1867

    There are many more, but the chapter on Joseph Lister was horrifying. In his day, the mark of a good surgeon was how bloody his smock was. They kept a role of suture thread in an inside pocket and pulled it out a button hole when needed. They NEVER washed their hands or their tools. Needless to say, in those days, surgery was pretty much a death sentence due to sepsis. Lister was almost run out of their society for wearing clean clothes, washing his hands, and sterilizing the surgical suite with carbolic acid…but his patients lived.

    After reading this book, I’m tempted to fall on my knees and give thanks for all these great men and that we live in the time we do.

  24. As to sepsis …
    Symptoms are so diffuse unless trained, I mean really trained, you can’t really tell what is what.

    So it is.

  25. G6loq:

    Actually, the symptoms are rather clear, when it’s starting to get really bad. At first it resembles a mild illness, or maybe people just feel a bit bad in a general way, or have a localized infection.

    When it’s getting severe, the most important symptoms are fast breathing, reduced urination, and confusion. Those are not diffuse, general symptoms. They are fairly specific, especially when seen in concert. Of course, the confusion can make it hard for the patient to put it all together, but people around them could connect the dots.

  26. Sepsis is a bacterial process that always has a source. An infected foot blister, in young Coolidge’s case.
    It is not a process that just comes swooping out of the blue, knocking people off left and right. Not like the 1918 flu. Sepsis is not contagious in the conventional sense.

    “Get to a good hospital immediately. This is an enormous and critical emergency.” Isn’t that agitated?

  27. I had no idea. I’ve never known of anyone in my family or friends who died of sepsis. The number of commenters who have known someone really confirms how common it is.

    As a kid of six I cut my foot on a rock, then hiked two miles to the trailhead. The cut was filled with dirt. The doctor cleaned it thoroughly (that was very painful), gave me a tetanus shot, and packed it with sulfa (the antibiotic of the time) and bandaged it. The bandage was changed frequently with new sulfa sprinkled into the wound each time. The doctor chewed me out for being so careless. Since that time I have always been very careful about tending to even minor scratches. Polysporin is always close at hand, whether traveling of at home.

    I consider this a real public service article and will share it with all my e-mail correspondents. Thank you, Neo.

  28. Frog:

    Do you not understand what I have written? You and I often disagree, but you’re not usually THAT obtuse

    I have never said if a person has an infection they need to race to the hospital. In fact, I wrote (and please read this carefully rather than quickly):

    Sepsis develops with lightening speed in situations in which the patient often isn’t even aware of the location of the infection. Certainly, even today a blister such as the one Coolidge’s son had is not usually treated with antibiotics, or effective antibiotics; we don’t need to take antibiotics for every small scrape or scratch (most of which will never be infected), and some bacteria are drug-resistant (sepsis can sometimes follow fungal, parasitic, or viral problems, too, but that’s not as common).

    I didn’t say there was no infection; I said the patient is often not aware of the location of the infection. Surely you understand the difference. If a person is unaware that he/she has an infection, or just feels vague malaise from it and is unaware of the source of the infection, that person can still get sepsis.

    I also believe it is clear in the post that when I speak of going to the hospital immediately I am talking not about regular sepsis but about severe sepsis or septic shock, the symptoms of which I list, and are different from the symptoms of a simple infection or early sepsis. I wrote:

    …by the time a patient has low blood pressure, something called septic shock is probably setting in, and multiple organ failure can occur within hours, even with the most heroic efforts known to modern medicine.

    I quote the following information that clearly states it is describing severe sepsis and the septic shock:

    Severe sepsis occurs when a patient with documented sepsis goes on to develop acute organ dysfunction with hypoperfusion and tissue hypoxemia. The most commonly affected organs are the kidneys, lungs, heart, and blood vessels. In some cases, neurologic or hepatic dysfunction may be the primary organ dysfunction.

    Finally, the patient may develop septic shock (also called distributive shock) from volume loss in the core circulation and poor circulatory support. Typically, septic shock causes a life-threatening blood pressure drop, reduced urine output, and body temperature changes–late signs of inadequate tissue oxygenation. Unless detected and treated early, it can spiral quickly into multisystem failure and death. Severe sepsis is the most common cause of death among patients in noncoronary critical care units.

    It is after that that I wrote, towards the end of the piece, “I don’t want to scare you, but I feel the need to alert you…Recognize those signs: the person feels bad, usually has a fever but not always, has a rapid heartbeat and respiration rate, sometimes trouble breathing, and often reduced urine output. Get to a good hospital immediately. This is an enormous and critical emergency. ”

    And your response is to say sepsis isn’t contagious? When did I ever indicate it was? Never. And then you call my response “agitated”? The proper word is “urgent” and even “appropriately urgent.” If a person has those symptoms I listed (which you conveniently left out), particularly a high respiration rate and reduced urine output, the situation is potentially dire, and people need to have it checked out, pronto, because every hour lost in severe sepsis (septic shock) is associated with an 8% increase in mortality.

    Maybe you think a person should yawn when confronted with such a situation, but I think it suggests a certain urgency is in order.

    By the way, your statement that “Sepsis is a bacterial process that always has a source” is untrue. Let me correct you: “Severe sepsis is an inflammatory process that is a reaction to a bacterial, fungal, parasitic, or viral process that always has a source, although sometimes the source and the original site of the source are never exactly determined.”

    There. Fixed it for you.

  29. g6loq — Ignaz Semmelweis wasn’t in this particular book. Thanks for letting me know about him.

  30. Wow.

    I had blood poisoning as a teen. Got a cut on my foot, did not apparently clean thoroughly, but used the new spray-on bandage we’d just bought. Sprayed it a couple of times more in the next few days.

    It got horribly infected, and my foot started turning black up to the ankle. I complained to the school nurse, who didn’t even check it, but sent me back to class. I walked out of school (I must have been an ornery little bugger), made it home, and fortunately, my mother took me right to a doctor. LOTS of antibiotics, and, after a week or two, I was better.

    I had no idea how close I came to losing that foot, or my life, until years later, when I was talking to a doctor.

  31. Linda F:

    It sounds as though you did not have severe sepsis, the runaway inflammatory reaction I’m writing about here. However, you certainly had a very dangerous infection that threatened the loss of your limb.

  32. For God’s sake, Frog. Should my family not have been “agitated” to realize that the lovely young woman who is now my daughter-in-law would have died in a matter of a few hours if not for the fact that my son, who’d never heard of either sepsis or meningococcemia – unlike you in your lordly medical wisdom – got “agitated” enough about her early symptoms to take her to the ER before the full-blown syndrome set in? Do you not understand that the person whose agitation you’re sneering at has a friend who’s dying of this condition as we write about it? Neo is trying to educate people who don’t know about this, in hopes that some people may be saved through early intervention, just as my daughter-in-law was saved, while her friend was not. Your condescension is hideous, and I feel sorry for your patients.

  33. G6loq, unfortunately, you’re right that even with training, sepsis is hard to diagnose in its early stages. I took my mother to the doctor on the morning of the day her sepsis began. At that point her primary symptoms were fatigue and confusion. After what I truly believe was a careful, caring and exacting examination, the doctor sent us home, advising me to take her to the ER if she got worse. Hours later, she did, I did, and she was diagnosed – but by the time her symptoms were clear, she was already desperately ill.

  34. I knew someone who died from sepsis many years ago. I worked with her daughter. She was fine on Monday, she thought, but by Saturday, she was dead. That scared the heck out of me. I can’t remember what led to the infection. But it was a week of hell.

    I also know a young man who recently survived a bout with sepsis — came about from a tooth infection. Spent a long time in the hospital. He was only about 25. But he’s doing fine now.

    My dog developed a perforated ulcer and was diagnosed with peritonitis. (She had been taking metacam long term. If I had known, I would not have given it to her.) Peritonitis can lead easily to sepsis. I went ahead and made the decision to repair the perforated ulcer — the peritoneal lavage had actually tested negative for bacteria, so I figured there was a chance. I also knew if if she developed sepsis, that was it for her — for a dog, as much as I love her, it would not have been a battle worth fighting. The survival rate for sepsis among domestic house pets is less than 10%. And if she did survive, there was a high probability that her artificial hip would irreparably fail.

    This was four years ago. She’s still around, and asking me to take her for a walk right now…

  35. This will keep you all awake nights: Frontline’s frightening documentary “Hunting the Nightmare Bacteria,” about the worldwide scourge of Gram-negative bacteria that nothing in our arsenal can kill. Riveting:

    http://www.pbs.org/wgbh/frontline/film/hunting-the-nightmare-bacteria/

    Our aunt nearly died after a knee replacement — MRSA — and was on intravenous antibiotics for eight weeks.

    I don’t know if these bacteria can cause sepsis[?], but they’re lethal, too.

  36. Neo, everyone: I’m so sorry you have all suffered from this. Truly dreadful. And thank you, Neo, for the information. I’ll pass it on to all my kith and kin. Hugs, Beverly

  37. Well! This might have been merely an interesting, helpful article EXCEPT that I have surgery scheduled for this coming Thursday! I already know that hospitals are riddled with bacteria and viruses, but this article and the posts with examples have about destroyed my peace of mind.

    With that, I will say, “Good night.” 😉

  38. Thanks for the info.

    I suffered a pulmonary embolism without knowing it. Six months later I got pneumonia. Didn’t realize I had a problem until I coughed up blood on my way out the door to do a 20 mile run. I’d been hurting a bit before but I thought I’d sprained my ribs, because that what was the pain felt like.

    The symptom I ignored was the feeling I was only firing on three cylinders instead of four. This happened after a horrible flight from Hawaii to Ohio. But a marathon runner doesn’t really notice that, except on repeated hill runs.

    Subsequently, I learned that endurance athletes with low heart rates are vulnerable to pulmonary embolisms on long flights or drives.

    Lesson learned: If it feels off, get it checked.

  39. Neo, I am so sorry to hear about your friend, and you are doing a great service in providing this information. It happened to my elderly father a few years ago. He and my mom were on an overnight trip for a class reunion and my dad became very sick, very quickly in the hotel room. Because he has had various heart problems my mom is always on red alert and hustled him to the nearest emergency room. He was admitted and spent days fighting off sepsis and thankfully is still with us today. But if he hadn’t been able to get to a nearby hospital quickly it would have been a different story. My prayers for your friend.

  40. Frog, sepsis not always is a bacterial process, it can be triggered by viral infection as well. Essentially, it is a generalized inflammatory response to alien antigen – bacterial or not. The 1918 flu was so deadly exactly because it quite often resulted in sepsis, just as ebola infection. Antihistamine therapy is needed to prevent septic shock, the main killer leading to poly-organ failure. There is a need for dialysis and blood sorbtion which can be done only in hospital, and not every hospital has such equipment. Time is crucial, histamine shock develops in minutes.

  41. One good thing about sepsis, it seems to have killed Reinhard Heydrich about a week after four brave Czechs attempted to assassinate him in Operation Anthropoid.

  42. My former partner – the one I mentioned yesterday – just died from sepsis, two weeks to the day after he attended the football game I described, and 3 or 4 days after the sepsis was diagnosed.
    Thank God for hospice care; the subject is depressing but they do a great job of relieving [physical] pain.

  43. Essential oils for first aid. Winterleaf, peppermint, melaleuca, eucalyptus. Last 3 internal as well as external application. Well, there’s a lot of other stuff, like drinking a lot of water, doing chi gong, and using breath controls to regulate internal body functions.

    Regulating the body consciously or not, and preventing diseases is a lot easier than trying to fix a problem once it gets into the critical stages later on.

  44. Pingback:The Bookworm Beat 12-12-15 — the “hopeful pessimist” open thread

  45. Pingback:The Bookworm Beat 12-12-15 — the “hopeful pessimist” open thread | H2o Positivo

  46. My husband had sepsis, while being treated for pneumonia. His kidneys failed and they put him on dialysis. But it was really the pneumonia that destroyed his lungs that killed him.

    And at the same time, my now husbands wife was in the hospital with lung cancer. She also came down with sepsis. And it was primarily the lung cancer that killed her. I guess it’s easier to diagnose sepsis if they are already in the hospital. It just adds another horror to deal with.

    I’m sorry about the loss of your friend.

  47. Terripitman:

    Thank you. Sorry for your loss. My friend’s lungs were the problem in the end, too.

  48. I am so sorry about your friend Neo.

    I had one friend who had this and she is OK but was in an isolated ward in the hospital. I don’t think she entirely knew how serious it was, that she had a stronger chance of dying than of living, and I didn’t tell her either. But she knew it was dire. She made it, thank goodness. But it was close.

    Thank you for this info as I did not know as much as I do now. It is good to be aware.

  49. liberty wolf:

    I’m really glad your friend pulled through. It’s a nasty, nasty illness. I really hadn’t known much about it before this happened, either, and I consider myself fairly medicine-literate.

  50. Hi all,

    I am a survivor of septic shock and all the crap that led to it. Mine developed after I somehow blew a hole in my colon. Colon leakage is typically a pinhole, but no—I blew a hole the size of a quarter. I was just fine, and started experiencing abdominal pain. Within an hour, I was in the ER and unable to communicate due to pain and medications they started. Took them a day to finally decide to open me up to see what was going on (CT showed nothing in ER’s defense). Post surgery (needed second surgery within week) I was on IV antibiotics and receiving multiple treatments. Eighteen days in ICU, on Vent for over a week, multiple organ failure ensued (respiratory, cardiac, hepatic, renal, cognitive- you name it!). Don’t know how I made it? Surgeon labeled me her Miracle patient. At one point I had as many as 25 substances being pumped into me, with 24-hour 1:1 nurses in attendance. The fortunate thing was that I was at a fairly decent hospital that instituted appropriate care, despite the delay in figuring out what was going on inside me. I shudder to wonder what might have happened if I were in a small community hospital with many fewer resources. Other things that helped was a spouse who monitored everything that went on around me. Even medical staff make mistakes, but asking questions and keeping records kept everyone on-point. Didn’t hurt that a nun I worked with championed the faithful to pray for my recovery.

    Someone mentioned the extreme recovery period. I was in hospital for 67 days and really was not ready to go home then. On IV antibiotics for 4-5 months; 12 surgical procedures over the next year, and a loss of 30% of body weight (not a good way to lose it!). After the first year, the real recovery began. Had a complex abdominal wall repair, an ostomy reversal, and another year of physical therapy. Had to travel to a larger teaching hospital in another city for the repair. Third year has been better. Body is somewhat limited in strength compared to pre-surgery, but pretty functional again, without much pain.

    As others have noted, I knew the term sepsis, but had little understanding about it. It hit like a train-load of bricks! Hard as hell, and faster than one could imagine. No red flashing lights or dinging bell warnings!

    Not sure I could have recognized this myself due to my being the target, but the real message is for all of us to be vigilant when one of our family or friends becomes rapidly ill, and ACT. Be respectfully pushy if you need to with medical staff. They mean well, but they also are working with little information at times. Ask for specialists beyond the ER if multiple organ systems seem to be involved. Don’t be reluctant to transfer to a major hospital if you are in a small hospital with few resources. As patient’s family, ask other family/friends for help–you will need it. Good luck too; that was also at play for me!

Leave a Reply

Your email address will not be published. Required fields are marked *

HTML tags allowed in your comment: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <s> <strike> <strong>