Monday, June 10, 2019

Hoito pidentää elämää 8 viikkoa


Hoito pidentää elämää 8 viikkoa

Tietävätkö lääkärit syöpäpotilaan elämän pituuden? Eivät. Tietävätkö lääkärit miten paljon jokin hoito pidentää potilaan elämää? Eivät. Tilastoista kuitenkin on luettavissa, miten mediaanipotilaat ovat aiemmin pärjänneet.

Levinneen syövän hoidosta puhuttaessa saatetaan todeta, että “hoito pidentää elämää X viikkoa”, synnyttäen mielikuvan, että olisi tiedossa miten pitkään potilas tulee elämään. Näin ei kuitenkaan ole. Elämän pituutta eivät lääkärit tiedä, vaikka olisivat kuinka viisaita ja taitavia. Myöskään potilaan ennustetta ei kukaan tiedä. Tulevaisuuden tietäminen on ennustamisen lajeista vaikeimpia, varsinkin etukäteen.

Elokuvissa ja sarjoissa lääkärit osaavat usein kertoa potilaalle ja omaisille: ”teillä on X kuukautta jäljellä”. Potilaille ja omaisille on hieno asia pystyä parempaan, ikään kuin voittaa ennuste. Joka toisessa tapauksessa tuleekin tilaisuus lähettää vaikkapa postikortti, kun X kuukautta on ohittunut. ”Annoit minulle 8 kuukautta, mutta nyt on mennyt jo 11 ja henki pihisee vielä”. Mitä lääkärit oikein tarkoittavat antaessaan jonkin luvun elämän pituudeksi?

Elämän pituudella tarkoitetaan mediaanielossaoloa

He tarkoittavat mediaanielossaoloaikaa. Mediaani ei ole keskiarvo, vaan järjestetyn joukon keskimmäinen alkio. Eli jos otetaan joukko potilaita jotka sairastavat levinnyttä syöpää X, ja järjestetään elossaolon pituudet numerojärjestykseen, niin mediaani tarkoittaa keskimmäistä numeroa. Mediaani on biologiassa ja lääketieteessä havainnollisempi kuin keskiarvo (englanniksi mean), sillä keskiarvoon vaikuttavat voimakkaasti ääritapaukset. Jos potilasjoukossa on joitakin jotka elävät vaikka 50 vuotta, niin keskiarvo voi olla korkea, vaikka valtaosa potilaista eläisikin vain vuoden tai pari. 

Mistä lääkärit sitten tietävät mediaanin? Mediaani on luettavissa tilastosta, ja lääkärin oma kokemuskin auttaa. Jos potilas sairastaa syöpää X ja kysyy: ”miten pitkään elän”, lääkäri muistaa jonkin oppikirjan tai esitelmän jossa kerrottiin, että levinnyttä syöpää X sairastavien mediaanielossaoloaika oli Y kuukautta. Se unohtuu kyllä joskus lääkäreiltäkin, että mediaani on vain tilastotieteellinen käsite, eikä kukaan potilas ole juuri tuo mediaanipotilas.

Mediaanipotilasta ei ole olemassa, sillä tieteellinen artikkeli kertoo potilasjoukosta, joka on aikanaan kerätty joillakin kriteereillä. Tämä on tapahtunut menneisyydessä, kun vastaanotolla istuva potilas elää nykyisyydessä. Tieteellistä informaatiota ja tilastoja tulkittaessa onkin tärkeää muistaa, että ne kertovat aina menneisyydestä, eivät nykyisyydestä, puhumattakaan tulevaisuudesta. Hoitojen jatkuvasti kehittyessä voidaan esittää, että vanhat tilastot voisi heittää romukoppaan, koska ne perustuvat hoitoihin jotka ovat korvaantuneet uusilla.

Kyynikot voivat ihmetellä miksi joku syöpälääke on hyväksytty, jos se pidentää elämää vain 8 viikolla? Tällaisen kommentin esittäjä ei ymmärrä, että hän tarkoittaa tutkimusaineistossa raportoitua mediaanihyötyä. Yksittäinen potilas voi hyötyä vähemmän tai enemmän. Hoito voi jopa lyhentää elämän pituutta. Ja osa potilaista voi saada huomattavan hyödyn, ja elää jopa vuosia. Yleensä kukaan ei tiedä mihin ryhmään potilas kuuluu. Jos asia olisi mahdollista määrittää, niin kannattaisi tietenkin hoitaa vain ne ketkä tulevat hoidosta hyötymään, ja antaa muille jotakin muuta lääkettä. Tällaisen testin nimi on biomarkkeri.

Biomarkkerit voivat kertoa kenelle hoidosta on hyötyä

Syövän hoidossa on valitettavan harvinaista, että käytettävissä olisi jokin toimiva biomarkkeri. Joitakin biomarkkereita on kuitenkin rutiinikäytössä. Osa rintasyövistä ilmentää Her2-tekijää. Jos tuumorissa on Her2, voidaan käyttää Her2-estäjiä. Her2 estäjistä on tieto, että ne eivät hyödytä, jos Her2-tekijä puuttuu, mutta ne voivat auttaa vaihtelevan määrän, jos Her2-tekijää on. Osa potilaista hyötyy enemmän, osa vähemmän. Sellaista testiä ei ole, jolla voitaisiin sanoa, että jokin Her2-positiivinen potilas saa vuosia kestävän hyödyn tai vain lyhyen hyödyn. 

Muita yleisiä biomarkkeritestejä ovat vaikkapa estrogeeni-ja progesteronireseptorin määrittäminen rintasyövistä, tai tiettyjen mutaatioiden määrittäminen keuhkosyövässä tai melanoomassa. Nämä biomarkkerit ovat samanlaisia kuin Her2. Biomarkkerin puuttuminen käytännössä tarkoittaa, että kohteen estäminen ei kannata, mutta markkerin olemassaolo ei takaa hyötyä tai määritä sen pituutta.

Yksittäisten potilaiden elossaolo muodostaa jakauman

Biomarkkerinkaan määrittäminen ei siis kerro miten pitkään potilas tulee elämään, hoidolla taikka ilman, vaan ainoastaan, kuinka pitkään mediaanipotilas oli elänyt jossakin kliinisessä tutkimuksessa. Ainoa keksimäni tapa selittää mediaanin merkitys on piirtää potilaalle paperille käyrä (Kuva 1). Kunkin potilaan elossaolon pituus näkyy pisteenä kuvassa. Pisteitä on eniten lähellä käyrän keskiosaa, mutta kummastakin ääripäästä löytyy myös tapauksia.

Erityisesti käyrän oikea laita on kiinnostava potilaan ja omaisten kannalta. Sieltä löytyy potilaita, joiden elossaolo on varsin pitkä, jopa kuukausia tai vuosia pidempi kuin mediaani. Tämä tarkoittaa sitä että, vaikka hoitoa X saavan potilaan mediaanielossaolo olisi Y kuukautta, pieni osa potilasta elää Z vuotta. Koska yleensä puuttuu testi näiden potilaiden tunnistamiseksi, hoidetaan kaikki potilaat jotka täyttävät hoidon kriteerit. Seurannassa sitten selviää hyötyikö potilas vähän, paljon, vai ei ollenkaan. 



Tärkeää on myös huomata, ettei potilaita hoideta sokkona. Mitä tahansa hoitoa aloitettaessa pitää olla jotakin jolla mitata hoidon tehoa. Tyypillisesti se on jokin tarkka kuvaus, vaikkapa tietokonetomografia tai magneettikuvaus. Hoitoa annetaan jonkin aikaa, esimerkiksi 6-8 viikkoa, ja sitten kuvaus tehdään uudelleen, ja verrataan. Jos kasvaimet kasvoivat, hoito kannattaa ehkä vaihtaa. Jos kasvaimet pienenivät tai pysähtyivät, hoito on ehkä tehoamassa. 

Kaplan-Meier käyrällä voidaan verrata hoitojen vaikutuksia elossaoloon

Kun puhutaan hoidon tehosta, tarkoitetaan usein kahta tai useampaa hoitoa vertailevaa ”Kaplan-Meier” elossaolokäyrää. Vertailu historiallisiin kontrolleihin on käytännössä merkityksetöntä, koska potilasvalintaan liittyy niin paljon virhetekijöitä. Siksi luotettavien vertailujen tekemiseksi tarvitaan satunnaistaminen. Se tarkoittaa sitä, että samoilla kriteereillä kerättyjä potilaita arvotaan saamaan joko hoito A tai hoito B. Usein arvonta ja jopa hoitokin sokkoutetaan, niin ettei hoitohenkilökuntakaan tiedä kumpaa hoitoa potilas saa.

Kun ”tapahtumia” on riittävästi, voidaan potilaiden elossaolo piirtää Kaplan-Meier käyrälle (Kuva 2).  Tyypillinen tapa tulkita tuloksia on katsoa milloin ryhmän mediaanielossaolo alittaa 50 prosenttia (vaakasuora katkoviiva). Kahden eri hoidon mediaanielossaolon 50 prosentin kohtaa vertaamalla saadaan ”hoidon hyöty” (T2-T1 tai T3-T1). Tämä ei suinkaan tarkoita sitä, että jokainen potilas hyötyisi tuon X viikkoa. Mediaanielossaolot ja niiden erot ovat itse asiassa vain tilastotieteellinen käsite, ja yksittäinen potilas voi hyötyä vähän, paljon tai ei ollenkaan. 



Ajatus mediaanielossaolojen vertailun hyödyllisyydestä levinneen syövän hoidossa perustuu vanhemman sukupolven syöpälääkkeisiin. Esimerkiksi sytostaattihoidot parhaimmillaankin tehosivat jonkin aikaa, jonka jälkeen tauti eteni, ja lopulta kaikki potilaat kuolivat. Silloin Kaplan-Meier käyrän alkuosan voi ajatella kuvaavaan tilannetta myös käyrän loppuosassa.

Mediaaniajattelu ei toimi immunoterapiassa

Immunoterapiassa ei kuitenkaan ole näin. Kaikki potilaat eivät välttämättä hyödy hoidosta, jolloin käyrän alkuosa voi näyttää kummassakin ryhmässä samalta (T2 ja T3 ovat lähellä toisiaan), mutta hoidosta hyötyvät alkavat erottua käyrän loppupuolella. Vaikuttaisi siltä, että kaikissa toimivissa immunoterapioissa voidaan todeta ”tasanne” (plateau), jolloin eloonjäämiskäyrä ei laskekaan enää, vaan jatkaa melkein vaakasuoraan (Kuva 2). Joistakin immunoterapioista on jo yli vuosikymmenen seuranta, ja on todettavissa, että hoidosta hyötyneet ovat edelleen elossa. On jopa alettu puhumaan parantumisista, mikä oli vielä jokin aika sitten tuntematon ilmiö useimmissa levinneissä kiinteissä kasvaimissa, eli muissa kuin veren syövissä.

Mediaanielossaolojen vertailua sotkee vielä ”cross-over”. Eettisistä syistä viime aikoina on alettu edellyttää sitä, että potilailla on oikeus vaihtaa ryhmästä toiseen jos tauti etenee. Tämä tarkoittaa sitä, että vaikka teoriassa vertaillaan hoitoa A ja B, itse asiassa iso osa kummankin ryhmän potilaista on lopulta saanut kumpaakin hoitoa, tai ainakin uudempaa ja kiinnostavampaa hoitoa A.

Lääkehyväksynnät perustuvat usein mediaanielossaoloon

Levinneen syövän lääkehyväksynnöissä on perinteisesti edellytetty näyttöä elossaolohyödystä, tarkoittaen tilastollisesti merkittävää pidentymistä mediaanielossaolossa (T2 > T1). Tässä ollaan kuitenkin vaikean tehtävän edessä, jos iso osa potilaista kummassakin ryhmässä on saanut uutta lääkettä A. Siksi onkin turvauduttu sijaismuuttujiin, kuten taudin etenemättömyysaikaan, tai ”vasteisiin”, joilla tarkoitetaan kasvaimien pienentymistä esimerkiksi yli 30 prosenttia.

Näissä sijaismuuttujissa on omat ongelmansa, erityisesti immunoterapiassa, jossa kasvain saattaa aluksi turvota, vaikka hoito on tehoamassa. Joissakin lääkkeissä on myös toisensuuntainen ongelma. Vaikka tauti stabiloituu aluksi, se alkaa sitten edetä nopeammin kuin ennen hoitoa. Tästä esimerkkinä toimivat vaikkapa verisuonten kasvua estävät lääkkeet.   

Yhteenveto

Yhteenvetona, kukaan lääkäri ei tiedä miten pitkään potilas elää. Lääkärin toimenkuvaan kuuluu kuitenkin arvioiden esittäminen, jos potilas niitä kysyy. Silloin tulisi muistaa, että arviot perustuvat menneisyyteen, jolloin käytössä oli ehkä varsin erilaiset hoidot. Tilastot kiteytetään usein mediaanipotilaaseen, joka ei kuitenkaan ole mikään oikea potilas. Yleensä ei ole etukäteen tiedossa mihin kohtaan elossaolokäyrää kukin potilas sijoittuu. 

Mediaanielossaolon pidentyminen on lääkehyväksyntöjen kulmakivi, vaikka siinä on useita heikkouksia. Kuitenkaan mitään helppoa ratkaisua tähän ei ole, sillä muuten se olisi käytössä. Taitava lääkäri osaa huomioida tilastotiedon, kliiniset tekijät ja potilaan toiveet, ja näillä perusteilla ehdottaa parhaiten soveltuvaa hoitoa.

Akseli Hemminki, LL, LT
Syöpätautien professori, syöpätautien ja sädehoidon erikoislääkäri

Viitteet

Hemminki A. Kuoleman Laakso. Voiko syöpää hoitaa kokeellisilla menetelmillä? Nomerta, Turku. Ilmestynyt englanniksi 2015 ja suomeksi 28.4.2016. http://www.nomerta.net/kirjat.php


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  11. Natural herbs have cured so many illness that drugs and injection can’t cure. I've seen the great importance of natural herbs and the wonderful work they have done in people's lives. i read people's testimonies online on how they were cured of HERPES, HIV, diabetics etc by Dr Ojoka herbal medicine, so i decided to contact the doctor because i know nature has the power to heal anything. I was diagnosed with HIV for the past 3 years but Dr Ojoka cured me with his herbs and i referred my aunt and her husband to him immediately because they were both suffering from Herpes but to God be the glory, they were cured too .I know is hard to believe but am a  living for testimony. There is no harm trying herbs Contact Email drojokarootandherbal@gmail com or whats app him +2348144172934

    ReplyDelete
  12. Hello everyone this is serious and real i want to tell the whole world about how DR DADA HERBAL MIXTURE product helped me enlarge my penis size ..i have trying since 25 years of age to enlarge my penis but none rendered me the help i want, i have used vaccines,penis pump,surgery,online creams from USA CAMBODIA,AUSTRALIA and many more but none of them enlarge my penis i was really frustrated and tired of living because my penis was too small ,imagine a cute and handsome 40 years old man like me having 3.5 inches and to make it worse i was having erectile dysfunction which was so annoying to me,my girlfriends have left me because of my small penis ....to GOD be the glory as i was searching for help on a Facebook page i saw one Mr Peter  from TEXAS testifying of how DR DADA HERBAL MIXTURE product enlarge his penis and healed his grand mom PROSTRATE CANCER .so i quickly  message him on his email drdadaspellhome7@gmail.com and he replied me and gave me comforting words and told me all i need to do and i was surprise when i got his product and he sent it to me through united parcel service (UPS) and i got it 4 days later and used the product just as he told me and its just 9 days of using his herbal mixture my penis is now 10 inches long and 8.0 flaccidity am so happy to feel like a man in the bedroom at last, so if you need penis enlargement,breast enlargement,weak erection,erectile dysfunction cure and many sexual relation cure do not hesitate to email him now drdadaspellhome7@gmail.com or drdadaspellhome@hotmail.com  you can also whatsapp him on +2348158568638 thanks

    ReplyDelete
  13. WITH THE HELP OF  DR PERFECT ENLARGEMENT CREAM MY PENIS GROW  FROM 3 INCHES TO 9 INCHES YOU CAN ON EMAIL AT SOLUTIONTOALLPROBLEMS1@GMAIL.COM

    Hello everyone I have to give my testimony about a herbal doctor called Dr Perfect. I was heartbroken because I had a very small penis not good enough to satisfy a woman, I have been in so many relationships but they were cut off because of my situation, I have used so many products prescribed by the doctor but none could render me the help I was looking for, so I decided to search online for solution and I saw a lot of comments about this specialist called Dr Perfect on how he helped people with small penis, cancer and others so I decided to give his herbal product a try, I messaged him on WhatsApp and replied me back, he gave me some comforting words we talked on how i can receive the product and he sent me his herbal product for penis enlargement, within 1 week of using it I began to feel the enlargement of my penis, now it just two weeks of me using his products my penis is about 9 inches longer, and I settle things with my girlfriend I was surprised when she said that she is satisfied with my performance in bed and am happy that i have a big penis now all thanks to Dr Perfect feel free to contact Dr Perfect at solutiontoallproblems1@gmail.com or WhatsApp him +1(256)251-3614 and get your enlargement cream 

    ReplyDelete
  14. I was despondent because i had a very small penis, about 2.5 inches soft and 4 inches hard not nice enough to satisfy a woman, i have been in so many relationship, but cut off because of my situation, i have used so many product which doctors prescribe for me, but none could offer me the help i searched for. i saw some few comments on the INTERNET about this specialist called Dr DADA and decided to contact him on his email: {drdadaspellhome7@gmail.com} so I decided to give his herbal product a try. i emailed him and he got back to me, he gave me some comforting words with his herbal pills for Penis Enlargement, Within 3 week of it, i began to feel the enlargement of my penis, " and now it just 4 weeks of using his products my penis is about 9 inches longer, and i had to settle out with my Ex girlfriend JOY, i was surprised when she said that she is satisfied with my sex and i have got a large penis. Am so happy, thanks to Dr DADA I also learn that Dr DADA also help with Breast Enlargement Hips and Bums Enlargement etc.. If you are in any situation with a little Penis, weak ejaculation, small breast_hips_bums do get to Dr DADA now for help on his email:{drdadaspellhome@hotmail.com} or whatsapp +2348158568638

    ReplyDelete
  15. Good day to all viewer online  am so happy sharing this great testimony on how i was checking for solution in the internet i came across Dr. Afrid the powerful herbalist that Cure Numerous individuals Herpes Simplex Virus,so I contacted him base on the testimonies I'm seeing about him on the internet, I was cured too by him, kindly contact him today through his email he can help you email; drafridherbalhome@gmail.com or you can visit his website drafridherbalhome.webs.com to know more about him or call/whatspp him on +2349057260738 and so he can cure types of diseases like, HEPATITIS B,DIABETICS,CANCER,HPV,LOW SPERM CAM HIV/STDS FIBROSIS LOST OF WEIGHT... all thank to you Dr Afrid for your kindly help in my life.

    ReplyDelete
  16. I want to share this wonderful testimony to the Good people all over the world on how I was able to Enlarge my Penis by Dr. Sikama. I was living a shameful life from my young age, just last month as I was browsing on the internet about Penis size and Enlargement Products, I saw a testimony of a Man called George , testifying of how he was able to get his penis Enlarged by Dr. Sikama and I decided to also Email Dr. Sikama for my small penis size and he quickly respond to me and gave me the normal instructions which i did and then he shipped the product to me here in the united state which i received in just 3 working days and today i am very happy because i started seeing positive changes in my penis size in just 7 days of use. Dr Sikama herbal product is the best recommended for you and to whom ever suffering from this shame or having any other diseases as well should Contact this great herbal doctor via his Email : adrsikama@gmail.com and WhatsApp Him on +7 926 503-80-12

    ReplyDelete
  17. Herbal Penis Enlargement product is 100% guarantee to Enlarge and get a better ERECTION , the reason why most people are finding it difficult to enlarge Penis is because they believe on medical report, drugs and medical treatment which is not helpful for Penis Enlargement . Natural roots/herbs are the best remedy which can easily Enlarge your Penis permanently Contact Dr Azuka via Email : dr.azukasolutionhome@gmail.com or via WhatsApp : +44 7520 636249 for Natural root and herbal remedies put together to help you get Enlarge and Erect healthy. Thank you.

    ReplyDelete
  18. AFRICAN TRADITIONAL METHODS OF CURING HERPES THAT IS GOING VIRAL!
    Most traditional methods of roots and herbs today have been scientifically proven to cure almost all drugs resistant diseases without after effect.
    It worked for me years ago when I was depressed with herpes. After trying numerous other methods, It was actually an old Ibo lady who brought to my notice the healing effect of natural medicines. She too was permanently cured from HERPES long time ago through Dr Utu @ "drutuherbalcure@gmail.com" who among few, specialises in African roots and herbs for medicinal cure. Apparently roots and herbs have well been known as effective key treatment for herpes. She introduced me to Dr Utu who till date remain my savior, and he truly cleared my doubt. After taking his medication on the fourth week, I contacted him again who asked me to go for test and I was negative. From then till now I do my normal business no outbreak. I may not be a herbal fan but it definitely worked for me!

    ReplyDelete
  19. i already gave up on ever getting cured of HSV2 because i have try many treatment none of them work out for me i have go to different hospital they always tell me same thing there is no cure for herpes when i came across a post about Dr ohunyom, in the net from a lady called Angela i contacted him and he reassured me with him herbal medicine which i took according to the way he instructed, that how i was cured. I doubted at first because i have been to a whole lot of reputable doctors, tried a lot of medicines but none was able to cure me. so i decided to listen to him and he commenced treatment, and under two weeks i was totally fee from #Herpes. i want to say a very big thank you to DR ohunyom for what he has done in my life. feel free to leave him a message on email drohunyom@gmail.com and also WhatsApp him +2349060579973..
    He can still be able to help you with this herbs medicine:
    1...ALS CURE/DIABETES CURE/EPILESY/HPV CURE/LUPUS/HEPATITIS/CANCER/GOUT      

    ReplyDelete
  20. i already gave up on ever getting cured of HSV2 because i have try many treatment none of them work out for me i have go to different hospital they always tell me same thing there is no cure for herpes when i came across a post about Dr ohunyom, in the net from a lady called Angela i contacted him and he reassured me with him herbal medicine which i took according to the way he instructed, that how i was cured. I doubted at first because i have been to a whole lot of reputable doctors, tried a lot of medicines but none was able to cure me. so i decided to listen to him and he commenced treatment, and under two weeks i was totally fee from #Herpes. i want to say a very big thank you to DR ohunyom for what he has done in my life. feel free to leave him a message on email drohunyom@gmail.com and also WhatsApp him +2349060579973..
    He can still be able to help you with this herbs medicine:
    1...ALS CURE/DIABETES CURE/EPILESY/HPV CURE/LUPUS/HEPATITIS/CANCER/GOUT      

    ReplyDelete
  21. Hello, everyone! I,m here to explore blogs and forum about the wonderful and most safe cure for (Herpes Virus).I was positive to the deadly virus called herpes and i lost hope because i was out casted and rejected even by my closet friends.i searched on-line to know and enquirer about cure for Herpes and i read someone testimony on how he was cured from Herpes so i decided to contact the same herbalist because i know that nature has the power to heal everything.i contacted him to know how he can help me and he told me never to worry that he will heal me with the natural herbs from God!after 2 days of contacting him, he told me that the cure has been ready and he sent it to me via DHL and it got to me after 3 days!i used the med as he instructed me (MORNING and EVENING) and i was cured!its really like a dream but i am so happy!thats the reason i decided to also add more comment of Him so that more can be saved just like me!and if you need his help, you can email him on nativehealthclinic@gmail.com, Instagram IG: @dremmanuel2 or whatsapp +2348140073965 I,m neme amber and you can get in touch with me via nemeamber@gmail.com..Contact him for help at Herpes virus HIV/AIDS CANCER COPD BRAIN TUMOR All kind of virus and disease //...

    ReplyDelete
  22. Hello, everyone! I,m here to explore blogs and forum about the wonderful and most safe cure for (Herpes Virus).I was positive to the deadly virus called herpes and i lost hope because i was out casted and rejected even by my closet friends.i searched on-line to know and enquirer about cure for Herpes and i read someone testimony on how he was cured from Herpes so i decided to contact the same herbalist because i know that nature has the power to heal everything.i contacted him to know how he can help me and he told me never to worry that he will heal me with the natural herbs from God!after 2 days of contacting him, he told me that the cure has been ready and he sent it to me via DHL and it got to me after 3 days!i used the med as he instructed me (MORNING and EVENING) and i was cured!its really like a dream but i am so happy!thats the reason i decided to also add more comment of Him so that more can be saved just like me!and if you need his help, you can email him on nativehealthclinic@gmail.com, Instagram IG: @dremmanuel2 or whatsapp +2348140073965 I,m neme amber and you can get in touch with me via nemeamber@gmail.com..Contact him for help at Herpes virus HIV/AIDS CANCER COPD BRAIN TUMOR All kind of virus and disease //...

    ReplyDelete
  23. Dr ohunyom herbal medicine is a good remedy for herpes simplex virus cure. My name is Mary Lora  ,I just want to share this article about Dr ohunyom who helped me, i want to inform the public how i was cured from (HERPES SIMPLEX VIRUS) by DR ohunyom, i visited different hospital but they gave me list of drugs like Familiar , Zovirax, and Valtrex which is very expensive to treat the symptoms and never cured me. I was browsing through the Internet searching for remedy on HERPES and i saw comment of people talking about how DR ohunyom cured them, when i contacted him he gave me hope and send a Herbal medicine to me that i took and it seriously worked for me, am a free person now without any problem, my HERPES result came out negative, I pray to God to never let me and my family forget you in our life,i am now cured permanently.you can also get your self cured, if you really need this dr's help,you can reach him now email:drohunyom@gmail. com Or whats app +2349060579973
    This is real,
    He also has herbal cure for the Following DISEASES, eczema,urethra wart,chronic problems.Herpes, Cancer, Als,Hepatitis, Diabetes, HPV,Infections,ulcer ETC

    ReplyDelete
  24. Dr ohunyom herbal medicine is a good remedy for herpes simplex virus cure. My name is Mary Lora  ,I just want to share this article about Dr ohunyom who helped me, i want to inform the public how i was cured from (HERPES SIMPLEX VIRUS) by DR ohunyom, i visited different hospital but they gave me list of drugs like Familiar , Zovirax, and Valtrex which is very expensive to treat the symptoms and never cured me. I was browsing through the Internet searching for remedy on HERPES and i saw comment of people talking about how DR ohunyom cured them, when i contacted him he gave me hope and send a Herbal medicine to me that i took and it seriously worked for me, am a free person now without any problem, my HERPES result came out negative, I pray to God to never let me and my family forget you in our life,i am now cured permanently.you can also get your self cured, if you really need this dr's help,you can reach him now email:drohunyom@gmail. com Or whats app +2349060579973
    This is real,
    He also has herbal cure for the Following DISEASES, eczema,urethra wart,chronic problems.Herpes, Cancer, Als,Hepatitis, Diabetes, HPV,Infections,ulcer ETC

    ReplyDelete
  25. I have used Dr Aziba herbal Medicine cure remedy for 2 WEEKS now. So far, it has cured my HERPES, eliminated my COLD SORE, improved energy and metabolism, in the morning I feel recharged and I no longer feel sleepy after a meal. As for the scent, it does smell like motor oil but I chase it down with 100% Herbal medicine from Dr Aziba. twice a day AFTER a meal. I also experienced vivid dreams for about 5 days now it’s diminishing to during the first 2 or 3 hours of sleep . contact Dr Aziba: EMAIL: priestazibasolutioncenter@gmail.com or whatsapp +2348100368288 and He also have herbs medicine to cure some popular diseases....

    ReplyDelete
  26. I have used Dr Aziba herbal Medicine cure remedy for 2 WEEKS now. So far, it has cured my HERPES, eliminated my COLD SORE, improved energy and metabolism, in the morning I feel recharged and I no longer feel sleepy after a meal. As for the scent, it does smell like motor oil but I chase it down with 100% Herbal medicine from Dr Aziba. twice a day AFTER a meal. I also experienced vivid dreams for about 5 days now it’s diminishing to during the first 2 or 3 hours of sleep . contact Dr Aziba: EMAIL: priestazibasolutioncenter@gmail.com or whatsapp +2348100368288 and He also have herbs medicine to cure some popular diseases....
    Some other areas of your health you may need Dr Aziba help to get cured.
    {1}Diabetes
    {2}HPV
    {3}ALS
    {4}Herpes
    Contact
    Dr via Email: Priestazibasolutioncenter@gmail.com
    WhatsApp : +2348100368288

    ReplyDelete
  27. My Name is Dr sebi you can Contact Me via Email drsebicurecenter@gmail.com For Penis Enlargement Product to help you get as long as 8inches Long with good Erection. Contact Me Via Email : drsebicurecenter@gmail.com Via WhatsApp +2347010538590

    ReplyDelete
  28. My name is Joel dwin  am from Texas US. I want to share a testimony of how Dr DADA herbal mixture product saves me from shame and disgrace, my penis was a big problem to me as the size was really so embarrassing,and i was also having weak erection problem. I cant make love to my wife and my penis was just too small, a full grown man like me having 4 inches penis and to worsen it i don't last in sex, i cant even last two minutes it was really a thing of shame to me. My wife was really tired of me because my sex life was very poor,she never enjoyed sex,i was always thinking and searching for solutions everywhere until when i saw a testimony of how Dr.DADA  herbal product have been helping people regarding their sex life, so i decided to give him a try and to my greatest surprise in less than one week of taking the herbs my penis grow to 8 inches i couldn't believe my eyes and as i speak now my penis is now 8 inches and i do not have week erection again. I can make love to my wife longer in bed. And my marriage is now stable,my wife now enjoy me very well in bed. You can contact him via drdadaspellhome7@gmail.com call or whatsapp him +2348158568638

    ReplyDelete
  29. Hello everyone this is a testimony of how a man named Dr Thomas gave me the reason to be happy again.
    I was having small penis and weak erection problem. I can't even make love with my girlfriend for 7 minutes and my penis was just too small a full grown up man like me having 4 inches penis and to worsen it i can't even last more than 3 minutes in bed, it was really a shame to me. I came across Mr Williams  testifying on how Dr Thomas save him from shame too,  so I decided  to give a  try to his products.  So I talk with him he told me that all everything will be alright that my penis will increase after he is true with what he was about to do. At  forst I thought it was a joke but in less than a week after taking some of his products  my penis  increased from 4 inches to 7 inches and I started lasting in bed for 30 minutes.  So i  called him and told him about it he told me that it was just the beginning that I will also last longer than that.
    As I am talking with you now my girlfriend can now enjoy me in bed.
    you can contact him for  more information's. you can contact him on his email : (Doctorthomas73@gmail.com).
    Or you can also contact him on what's app :(+2348152190329).
    He is also specialize on the following:
    1.Body enhancement 
    2.COPD(Chronic obstructive pulmonary disease).
    Thanks for enlarging my penis sir,  I am so grateful.

    ReplyDelete

  30. Herbal Penis Enlargement product is 100% guarantee to Enlarge and get a better ERECTION , the reason why most people are finding it difficult to enlarge Penis is because they bedlieve on medical report, drugs and medical treatment which is not helpful for Penis Enlargement . Natural roots/herbs are the best remedy which can easily Enlarge your Penis permanently Contact Dr DADA via Email : drdadaspellhome7@gmail.com or via WhatsApp : +2348158568638 for Natural root and herbal remedies put together to help you get Enlarge and Erect healthy. Thank you

    ReplyDelete

  31. Herbal Penis Enlargement product is 100% guarantee to Enlarge and get a better ERECTION , the reason why most people are finding it difficult to enlarge Penis is because they bedlieve on medical report, drugs and medical treatment which is not helpful for Penis Enlargement . Natural roots/herbs are the best remedy which can easily Enlarge your Penis permanently Contact Dr DADA via Email : drdadaspellhome7@gmail.com or via WhatsApp : +2348158568638 for Natural root and herbal remedies put together to help you get Enlarge and Erect healthy. Thank you

    ReplyDelete
  32. NATURAL HERBS FOR CURING HIV, HERPES, HPV, HSV1&2, CANCER AND DIABETES

    I just experience the wonders of Dr Ohunyom herbs. God will continue to bless you Dr Ohunyom more abundantly for the good work you are doing in peoples life by curing them from different type of diseases. I will keep on testifying about your good work. I was diagnosed of herpes 6 months ago and my doctor told me that there is no cure. I did not believe him and i keep my faith up hoping that one day i will be cured from this horrible disease. One day i saw a post on HIV forum about a herbal doctor called Dr Ohunyom on how he cure people from diseases with his herbs and i quickly contact Dr Ohunyom on his email and explain my problem to him and he told me not to worry that he is going to cure me and truly he prepared the cure and send it to me through UPS and gave me instructions on how to take it. After two weeks of taken the herbal cure, i went to my doctor for checkup and my result show Negative and my doctor told me that there is no trace of herpes in my body and the virus is completely gone from my body. Everybody at the clinic rejoice with me and they all ask for Dr Ohunyom contact. You can contact Dr Ohunyom on his email:drohunyom@gmail.com or WhatsApp him on +2349060579973.and He also have herbs medicine to cured the following diseases; eczema,urethra wart,chronic problems.Herpes, Cancer, Als,Hepatitis, Diabetes, HPV,Infections,ulcer  ETC

    ReplyDelete
  33. Hello everyone i am here to share a testimony of how Dr.Thomas herbal mixture cream saved me from  shame i have tryed so many ways everywhere until when i saw a testimony of how Dr.Thomas herbal mixture cream have been helping people regarding their sex life, so i decided to give him a try and to my greatest surprise in less than TEN DAYS of taking the herbs my penis grow to 7 inches i couldn't believe my eyes and as i speak now my penis is now 9 inches and i do not have week erection again. I can make love to my wife longer in bed. And my marriage is now stable,my wife now enjoy me very well in bed. you can contact him for more information's.(Doctorthomas73@gmail.com) or call or what-apps him through +2348152190329. he also specialize on the following things 1. CANCER
    2. ALS (Lou Gehrig's disease)
    3. COPD (chronic obstructive pulmonary disease) 
    Thank you sir, you indeed save me. 

    ReplyDelete
  34. FINALLY FREE FROM HERPES VIRUS
    I thought my life had nothing to offer anymore because life
    became meaningless to me because I had Herpes virus, the
    symptoms became very severe and bold and made my family
    run from and abandoned me so they won't get infected. I gave
    up everything, my hope, dreams,vision and job because the
    doctor told me there's no cure. I consumed so many drugs but
    they never cured me but hid the symptoms inside me making
    it worse. I was doing some research online someday when I
    came across testimonies of some people of how DR WOBE
    cured them from Herpes, I never believed at first and thought
    it was a joke but later decided to contact him on the details
    provided and when I messaged him we talked and he sent me
    his herbal medicine and told me to go for a test after two
    weeks. Within 7 days of medication the symptoms
    disappeared and when I went for a test LoL and behold I was
    NEGATIVE by the Doctor Who tested me earlier. Thank you DR
    WOBE because I forever owe you my life and I'll keep on
    telling the world about you. If you are going through same
    situation worry no more and contact DR WOBE via
    drwobeherbalhome@gmail.com or WhatsApp him via +2349064851206.
    he also special on curing HIV/AIDS2. HERPES, CANCER,
    ALS, HEPATITIS .DIABETES,  HUMAN PAPILOMA VIRUS
    DISEASE(HPV) ALZHEIMER  LUPUS (Lupus Vulgarism or
    LupusErythematosus  

    ReplyDelete
  35. I USED HERBAL MEDICINE TO CURE MY HERPES VIRUS  
    I am here to testify of the good work of Dr ROBINSON I was once a victim of Herpes Virus with lot of outbreaks on my body, I was cured from the Virus by the help of Dr.ROBINSON with his great Herbal medicine which is very active within 21 days with my Herpes result Negative, it is very active and it cost less. The doctors confirmed that the virus is no longer on my blood. You too can be cured contact him on his official email; drrobinsonspellhome@gmail.com. He has cure for HIV, Diabetes, Cancer, Fibroid, Painful joints, hepatitis, Heart disease and Liver disease.  

    ReplyDelete
  36. So surprise when i found that HSV 1&2 could be cured with Dr Ohunyom herbal remedy, this disease almost destroy my face, and my mouth with sores. i took many traditional medicine here in United state, but none could work. even visited my mother village in South africa still couldn't find a cure, but i was so surprise that after contacting Dr Ohunyom. And after done discussing with him i was cured with his herbal in 2 weeks. i confirmed his good work by my test result, do not delay to contact this true healer. Dr Ohunyom is able to help you in any challenges, HIV AIDS, HEPATITIS B, COLD SORES, CANCER, DIABETES, HEART DISEASE, BRAIN TUMOR, ACUTE BRONCHITIS And so many more. For more details Call or what app: +2349060579973 or Email: drohunyom@gmail.com.and  He also have herbs medicine to cured the following diseases; eczema,urethra wart,chronic problems.Herpes, Cancer, Als,Hepatitis, Diabetes, HPV,Infections,ulcer  ETC

    ReplyDelete
  37. So surprise when i found that HSV 1&2 could be cured with Dr Ohunyom herbal remedy, this disease almost destroy my face, and my mouth with sores. i took many traditional medicine here in United state, but none could work. even visited my mother village in South africa still couldn't find a cure, but i was so surprise that after contacting Dr Ohunyom. And after done discussing with him i was cured with his herbal in 2 weeks. i confirmed his good work by my test result, do not delay to contact this true healer. Dr Ohunyom is able to help you in any challenges, HIV AIDS, HEPATITIS B, COLD SORES, CANCER, DIABETES, HEART DISEASE, BRAIN TUMOR, ACUTE BRONCHITIS And so many more. For more details Call or what app: +2349060579973 or Email: drohunyom@gmail.com.and  He also have herbs medicine to cured the following diseases; eczema,urethra wart,chronic problems.Herpes, Cancer, Als,Hepatitis, Diabetes, HPV,Infections,ulcer  ETC

    ReplyDelete
  38. So surprise when i found that HSV 1&2 could be cured with Dr Ohunyom herbal remedy, this disease almost destroy my face, and my mouth with sores. i took many traditional medicine here in United state, but none could work. even visited my mother village in South africa still couldn't find a cure, but i was so surprise that after contacting Dr Ohunyom. And after done discussing with him i was cured with his herbal in 2 weeks. i confirmed his good work by my test result, do not delay to contact this true healer. Dr Ohunyom is able to help you in any challenges, HIV AIDS, HEPATITIS B, COLD SORES, CANCER, DIABETES, HEART DISEASE, BRAIN TUMOR, ACUTE BRONCHITIS And so many more. For more details Call or what app: +2349060579973 or Email: drohunyom@gmail.com.and  He also have herbs medicine to cured the following diseases; eczema,urethra wart,chronic problems.Herpes, Cancer, Als,Hepatitis, Diabetes, HPV,Infections,ulcer  ETC

    ReplyDelete
  39. So surprise when i found that HSV 1&2 could be cured with Dr Ohunyom herbal remedy, this disease almost destroy my face, and my mouth with sores. i took many traditional medicine here in United state, but none could work. even visited my mother village in South africa still couldn't find a cure, but i was so surprise that after contacting Dr Ohunyom. And after done discussing with him i was cured with his herbal in 2 weeks. i confirmed his good work by my test result, do not delay to contact this true healer. Dr Ohunyom is able to help you in any challenges, HIV AIDS, HEPATITIS B, COLD SORES, CANCER, DIABETES, HEART DISEASE, BRAIN TUMOR, ACUTE BRONCHITIS And so many more. For more details Call or what app: +2349060579973 or Email: drohunyom@gmail.com.and  He also have herbs medicine to cured the following diseases; eczema,urethra wart,chronic problems.Herpes, Cancer, Als,Hepatitis, Diabetes, HPV,Infections,ulcer  ETC

    ReplyDelete
  40. HOW DR PERFECT ENLARGEMENT CREAM HELP ME TO ENLARGE MY PENIS YOU CAN ADD HIM UP ON WHATSAPP +1(256) 251 3614

    My name is David Richardson from USA I want to share a testimony of how Dr Perfect herbal mixture cream saved me from shame and disgrace, my penis was a big problem to me as the size was really so embarrassing and I was also having weak erection problem. I can't make love to my wife and my penis was just too small, a full grown man like me having 3 inches penis and to worsen it I don't last long in sex I can't even last four minutes it was really a big shame to me. My wife was really tired of me because my sex life was very poor, she never enjoyed sex, I was always thinking and searching for solutions everywhere until when I saw a testimony of how Dr Perfect herbal mixture cream have been helping people regarding their sex life, so I decided to give him a try and to my greatest surprise in less than one week of taking the herbs my penis grow to 10 inches I couldn't believe my eyes and as I speak now my penis is now 10 inches long and I don't have weak erection anymore. I can make love to my wife longer in bed. And my marriage is now stable my wife is now enjoy me very well in bed. All thanks to Dr Perfect for enlarging my penis he indeed save my marriage. You can contact him at solutiontoallproblems1@gmail.com or you can add him up on WhatsApp +1(256) 251 3614. you can also view my blog http://davidrichardson12356.over-blog.com. He also specializes in the following things
    Herpes virus 
    Cancer
    Hsv
    Chronic venous disease
    and others 






    HOW DR PERFECT ENLARGEMENT CREAM HELP ME TO ENLARGE MY PENIS YOU CAN ADD HIM UP ON WHATSAPP +1(256) 251 3614

    My name is David Richardson from USA I want to share a testimony of how Dr Perfect herbal mixture cream saved me from shame and disgrace, my penis was a big problem to me as the size was really so embarrassing and I was also having weak erection problem. I can't make love to my wife and my penis was just too small, a full grown man like me having 3 inches penis and to worsen it I don't last long in sex I can't even last four minutes it was really a big shame to me. My wife was really tired of me because my sex life was very poor, she never enjoyed sex, I was always thinking and searching for solutions everywhere until when I saw a testimony of how Dr Perfect herbal mixture cream have been helping people regarding their sex life, so I decided to give him a try and to my greatest surprise in less than one week of taking the herbs my penis grow to 10 inches I couldn't believe my eyes and as I speak now my penis is now 10 inches long and I don't have weak erection anymore. I can make love to my wife longer in bed. And my marriage is now stable my wife is now enjoy me very well in bed. All thanks to Dr Perfect for enlarging my penis he indeed save my marriage. You can contact him at solutiontoallproblems1@gmail.com or you can add him up on WhatsApp +1(256) 251 3614. you can also view my blog http://davidrichardson12356.over-blog.com. He also specializes in the following things
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    ReplyDelete
  41. EFFECTIVE PENIS ENLARGEMENT THAT WORKS PERFECTLY
     i am from USA i am here to give my testimony about an herbal doctor called Dr,Gbojie I was heartbroken because i had very small penis,not nice to satisfy a woman, i have been in so many relationship, but cut off because of my situation, i have used so many product which doctors prescribe for me, but could not offer me the help i searched for. i saw some few comments on the internet about this specialist called Dr,Gbojie and decided to email him on his email i saw on the internet,(gbojiespiritualtemple@gmail.com   ) so I decided to give his herbal product a try. i emailed him and he got back to me, he gave me some comforting words with his herbal product for Penis Enlargement, Within three weeks of me use it, i began to feel the enlargement, " and now it just 4 weeks of using his products my penis is about 8 inches longer, and i had to settle thing out with my ex girlfriend , i was surprised when she said that she is satisfied with my performance in bed and i now have a large penis.thanks to DR Gbojie  for your herbal product. you can also reach him with  though his website : http://gbojiespiritualtemple.website2.me   
     or WHATASPP him today on this number (+2349066410185)

    ReplyDelete
  42. WHAT A GREAT MIRACLE THAT I HAVE EVER SEE IN MY LIFE. My names are Clara David I’m a citizen of USA, My younger sister was sicking of
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    ReplyDelete
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  44. My name is Clifford John from USA taxes, I want to share a testimony of how Dr_Ogodo1 herbal mixture cream saves me from shame and disgrace, my penis was a big problem to me as the size was really so embarrassing,and i was also having weak erection problem. I can't make love to my wife and my penis was just too small a full grown man like me having 4 inches penis and to worsen it i don't last in sex i can't even last two minutes it was really a thing of shame to me. My wife was really tired of me because my sex life was very poor,she never enjoyed sex,i was always thinking and searching for solutions everywhere until when i saw a testimony of how Dr_Ogodo1 herbal mixture cream have been helping people regarding their sex life, so i decided to give him a try and to my greatest surprise in less than one week of taking the herbs my penis grow to 8 inches i couldn't believe my eyes and as i speak now my penis is now 8 inches and i do not have week erection again. I can make love to my wife longer in bed. And my marriage is now stable,my wife now enjoy me very well in bed.
    * He can also bring back your Ex
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    ReplyDelete


  45. GREAT Dr Kabaka THAT HELP ME SAVE MY RELATIONSHIP... Good Day everybody, My name is Nancy am from Australia This is a very happy day of my life with the help of Dr Kabaka has rendered to me by helping me to get my husband back with his magic power and love spell. i was married for 8 years and it was so terrible because my husband was really cheating on me, and was seeking for a divorce but when i came across Dr Kabaka email on the internet on how he help so many people to get their ex back and help fixing relationship and make people to be happy in their relationship. i explained my situation to him and then seek his help but to my greatest surprise he told me that he will help me with my case and here i am now celebrating because my Husband has change totally for good. he started begging me to forgive him that he is very sorry for everything, i was really surprised and was also happy, so that was how i forgive him and now we are living together happily than ever before,and He always want to be by me and can not do anything without my present. i am really happy with my marriage, what a great celebration. thank you Dr Kabaka i will forever be grateful to you if you need his help you can contact him through his email address; drkabakaspiritualtemple@gmail.com
    OR call his whatsapp number on +2349015857861

    ReplyDelete
  46. OMG!! This is certainly a shocking and a genuine Testimonies. I visited a forum here on the internet on the 20TH OF OCT 2020, And I saw a marvelous testimonies of this powerful and great Doctor called PRIEST AZIBA on the forum. I never believed it, because I never heard nor learnt anything about Natural Enlargement Products. Nobody would have been able to influence me about Natural Enlargement Product not until PRIEST AZIBA did it for me and restored my Penis to a Normal size which i was very ok to have(11inch) he ask if I want to increase it further more i told him am ok with this I have now, so I’m recommending y’all in same situation to contact DR AZIBA via Email: PRIESTAZIBASOLUTIONCENTER@GMAIL.COM and also Contact him on his whatsApp +2348100368288 I am really short of expressions, and i don’t know how much to convey my appreciation to you PRIEST AZIBA you are a God sent to me and my entire friends whom has also use your product.. And now I am a joyful man with my family. here is DR Email and WhatsApp contact below Email: priestazibasolutioncenter@gmail.com & WhatsApp:+2348100368288









    OMG!! This is certainly a shocking and a genuine Testimonies. I visited a forum here on the internet on the 20TH OF OCT 2020, And I saw a marvelous testimonies of this powerful and great Doctor called PRIEST AZIBA on the forum. I never believed it, because I never heard nor learnt anything about Natural Enlargement Products. Nobody would have been able to influence me about Natural Enlargement Product not until PRIEST AZIBA did it for me and restored my Penis to a Normal size which i was very ok to have(11inch) he ask if I want to increase it further more i told him am ok with this I have now, so I’m recommending y’all in same situation to contact DR AZIBA via Email: PRIESTAZIBASOLUTIONCENTER@GMAIL.COM and also Contact him on his whatsApp +2348100368288 I am really short of expressions, and i don’t know how much to convey my appreciation to you PRIEST AZIBA you are a God sent to me and my entire friends whom has also use your product.. And now I am a joyful man with my family. here is DR Email and WhatsApp contact below Email: priestazibasolutioncenter@gmail.com & WhatsApp:+2348100368288

    ReplyDelete
  47. Hello, everyone! I'm here to explore blogs and forums about the wonderful and most safe cure for (Herpes Virus). I was positive about the deadly virus called herpes and I lost hope because I was outcast and rejected even by my closest friends. I searched on-line to know an enquirer cure for Herpes and I read someone's testimony on how he was cured from Herpes so I decided to contact the same herbalist because I know that nature has the power to heal everything. I contacted him to know how he can help me and he told me never to worry that he will heal me with the natural herbs from God! After 2 days of contacting him, he told me that the cure has been ready and he sent it to me via DHL and it got to me after 3 days! I used the med as he instructed (MORNING and EVENING) and i was cured! it's really like a dream but I am so happy! That's the reason I decided to also add more comments on Him so that more can be saved just like me! and you can get in touch with him via email chiefdrlucky@gmail.com WhatsApp +2348132777335

    ReplyDelete
  48. I was diagnosed with herpes virus i lived in pain with the knowledge that i wasn’t going to ever be well again i contacted so many doctors on this issue yet my condition never got better i was determined to get my life back so one day i saw Dr Odiase and told him my problems and all that i went through and he told me not to worry that everything will be fine again so he prepared the medicine and send it to me and told me how to use it, after 14days I went to see a medical doctor for test and the result was negative.i was so shocked and amazed,I'm the most happiest person on earth now.You too can also reach him via him personal email;(drodiaseherbalhome124@gmail.com or call/Whatsapp him +2349059435846 Thanks and God bless you Dr Odiase

    ReplyDelete
  49. Hello viewers I am glad to have met with the powerful herbal healer called
    Dr voodoo who use his herbs to cure my HIV disease I suffered from 15years,
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    ReplyDelete
  50. Awesome post such a nice article thanks for posting keep posting
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    ReplyDelete