Etiquette regarding medical dosing information March 15, 2011 12:44 PM   Subscribe

What are the guidelines for posting medical advice that could easily be administrated improperly?

Disclaimer, I'm a vet, and I'm a worrier.

Last week there was a thread where a kind and concerned cat owner asked some questions about a specific drug. In response, someone posted information including dosing instructions.

Potential problems posting dosing instructions:

-No drug concentration was noted, the drug in question comes in three concentrations.

-The dosing instructions given are in kilograms, some pet owners may not have access to a baby / small scale that would be accurate enough to get this information. Many pet owners would have no difficulty calculating the lbs to kilo ratio, then calculating the ideal dose and figuring out how many ml's that dose requires.... but I worry that it would be easy to make an error.

Is this the sort of thing I should flag, even though the response was probably useful to the pet owner, who was obviously in distress? Or just pet owner beware?

Thanks!
posted by Nickel Pickle to Etiquette/Policy at 12:44 PM (41 comments total) 2 users marked this as a favorite

This is the kind of thing I would flag, then I'd post exactly what you've typed here in-thread as a caution to the owner. No one is making the OP follow that advice, and at a distressing time, a dissenting but respectful voice can be helpful.
posted by phunniemee at 12:49 PM on March 15, 2011 [13 favorites]


I don't know that we reached any kind of consensus, but this has been discussed before with regard to non-furry pals
posted by juv3nal at 12:55 PM on March 15, 2011


Hey, it's this thread again! Hi thread, we missed you. What's up?

Flagging a comment because somebody might make an error doing trivial math when calculating the dose for an NSAID seems excessive to me. Might as well call for nothing to be allowed except "go see a doctor" answers. Which is what.... uh... whatshisname used to do. Before the flameout.
posted by Justinian at 12:59 PM on March 15, 2011


ikkyu2. And it wasn't so much a flameout as a belief that this community should not let itself be responsible for giving advice on such a sensitive and life-threatening subject.

Which is not to say that I agree completely, but to say that as a member of the community he was respected and well-liked, as far as I can tell, and that his opinions were valid.
posted by Night_owl at 1:06 PM on March 15, 2011 [1 favorite]


Yeeaaah, it was definitely a flameout. There was some rather sordid nastiness. But that's neither here nor there I guess.

The point is that this has come up before, repeatedly, and Ask Metafilter is very much a Caveat Emptor sort of place.
posted by Justinian at 1:13 PM on March 15, 2011


as a member of the community he was respected and well-liked, as far as I can tell, and that his opinions were valid.

As a member of this community, he was polarizing, is I think the best way to put it.

We tend not to approve anon questions asking about specific pharmaceutical things but if people want to ask on their own, usually we won't delete them. People adding cautionary information to a thread is absolutely okay. Flagging is usually something for when you want a mod to take a look at something. In this case, there's not really much we'd do. You'd be much better off emailing/MeMailing the OP or, preferably, adding a note to the thread. Orthogonality is a longtime user here and I'm sure he understands the things you can and can not expect the community to provide.
posted by jessamyn (staff) at 1:29 PM on March 15, 2011 [1 favorite]


I am not your vet.
posted by cjorgensen at 1:32 PM on March 15, 2011


Hey, my first call-out!

No offense taken or intended here, Nickle Pickle, but I'll stand by my answer and I'd probably post the same thing again in a similar circumstance. I understand your concerns, and I did waver a bit in my decision to comment, but I figured, this is information that is available on the Internet anyway, and it was not like I was suggesting a dosage for Ortho to use on his cat, I was merely confirming the dosage instructions already given.

I am firmly in the camp that says that many many kinds of advice given on Ask MetaFilter could have adverse consequences, and that it is a bit elitist to consider advice in fields like law and medicine to be somehow "more serious" than other fields.

As someone who knows a little bit about veterinary medicine, but is not a trained professional I am always glad to see vets and techs answering questions on Ask MetaFilter, and I really appreciated your follow-up answer in this case. I hope your concerns about giving advice over the Internet don't force you to stop commenting here.
posted by Rock Steady at 1:54 PM on March 15, 2011


RDVMs are just as scary as the internet. Not all of them, mind you, but it's scary what kind of medicine you will find these "trained professionals" practicing.

Best suggestion for something like this would be to get a second opinion... from a specialist.
posted by TheBones at 2:06 PM on March 15, 2011


No offense if you are an rdvm nickel pickle, not all RDVMs are scary.
posted by TheBones at 2:06 PM on March 15, 2011


Sorry.
posted by Night_owl at 2:31 PM on March 15, 2011


I don't get why this is a MeTa post instead of a comment in that thread.
posted by DU at 2:36 PM on March 15, 2011 [2 favorites]


If you see someone giving advice that is potentially liable to misapplication, definitely explain that in the thread!

Even general knowledge like "the safe dose depends on the animal's weight" is not always common sense as much as we might like it to be -- so pointing that fact out is very useful. After all, the asker might search other sites and get drug info there and misapply it.

If you can explain in a few clear sentences (as you've done here) why they shouldn't be figuring doses on their own, that's hugely valuable to the original poster and to anyone who finds the thread via Google later on. Much more valuable than having no information, since if they don't get the information they're looking for here they may look elsewhere, and will be no better off as far as knowing which situations they can figure on their own vs which they can't.
posted by LobsterMitten at 2:49 PM on March 15, 2011 [2 favorites]


Yea, if you have additional advice, please post it in thread. I thought that cat med thread was sorted out pretty nicely, but they definitely overlooked noting dosage.
posted by snsranch at 3:32 PM on March 15, 2011


Bad gardening advice can also fuck you up dead. Just ask the lawnmower man.
posted by It's Raining Florence Henderson at 5:32 PM on March 15, 2011 [4 favorites]


I don't get why this is a MeTa post instead of a comment in that thread.


I asked here about general etiquette practices, which seemed vague from the searches I did. Apparently I needed to remove the vet part of the equation, and my search might have yielded better results.

I didn't mean to offend Rock Steady in any way, it was appropriate advice, just incomplete and easy to use in a way that could cause permanent harm. Saying this is 'just an NSAID' is quite misleading, given the specific pharmacology. The threshold for damage is thin with this particular drug.

The_Bones, I totally agree... but then you and I are biased, aren't we!

Thanks everyone for the feedback. In the future I will just comment in the thread, and hope for the best.

Cheers!
posted by Nickel Pickle at 5:39 PM on March 15, 2011 [1 favorite]


I know that I specifically said in the thread that dose is important and amounts given in mLs mean nothing, and I'm pretty sure other people did too. I'm not really sure how you could see a dose in mg/kg and decide how many mLs that was without putting some thought into what you were seeing, like if it said 0.5 mg/kg would you just bung in 0.5 mL and not notice the discrepancy? Particularly when the vet already said 0.1 mL anyway?

Plus we weren't giving advice on what dose to give anyway, the person's vet had already done that. If you have some reason to think the vet was wrong and about to kill the cat then sure, say that, but otherwise why not assume that the trained and licensed professional that had diagnosed and treated the specific cat in person was doing their job correctly? The point of the thread was that this isn't some omg killer drug like some people seem to think it is, and there are cases where its careful use is entirely suitable. Plus some info about what that careful use entails (dose,age and health of cat, side effects to look out for, all were mentioned). I didn't see anyone telling them what to do with the drug specifically, and any extra advice about that specific cat needs to be given by a vet treating the actual cat (same one or second opinion).

It's not like they had the drug left over from another cat and asked for dosing guidelines, in that case I'd be worried about people throwing around numbers.
posted by shelleycat at 6:04 PM on March 15, 2011


I don't know that we reached any kind of consensus, but this has been discussed before with regard to non-furry pals

Man, there's some bad advice about LSD dosages in that previous thread. At the risk of a derail, a few reflections:

1. strongest acid I ever did was one of the smallest hits I've ever seen; stuff was called Windowpane and it was sort of a clear green plastic, maybe a sixth of an inch across.

2. second strongest acid I ever did was liquid. ONE drop from a lab-dropper was well more than enough. We took to putting one drop into a sugar cube, dropping sugar cube into a cup of tea, then once dissolved, sharing the cup of tea with at least one other person.

3. third strongest acid I ever was dubious looking, bought straight off the street corner, and very cheap.

Conclusion. YOU CAN NEVER TELL WHAT YOU'RE GETTING just by looking at it. Which gets us to the only "safe" approach (short of just not doing it anymore, which wouldn't be any fun):

Always half the first hit you get from a new supply. ALWAYS. If, after NO LESS THAN THREE HOURS, you still want to get higher, drop the other half. If after that particular trip, you decide that didn't get high enough, then maybe consider taking two hits next time.

DO NOT EVER JUST KEEP DROPPING MORE BECAUSE YOU'RE NOT FEELING ANYTHING YET ... unless you want to find yourself about nine hours later in the shallow water of the Pacific Ocean convinced that the ocean is in fact GOD HIMSELF and that God is hungry and slowly eating you.

Also, don't give acid to your cat. Ever.
posted by philip-random at 6:07 PM on March 15, 2011 [11 favorites]


philip-random's advice also applies to pot brownies, as I have learned the hard way.
posted by restless_nomad at 6:44 PM on March 15, 2011 [3 favorites]


I didn't mean to offend Rock Steady in any way, it was appropriate advice, just incomplete and easy to use in a way that could cause permanent harm.

No offense taken at all! It's a fair question you raise here, and you certainly filled in the holes in my answer appropriately.
posted by Rock Steady at 6:52 PM on March 15, 2011


DU writes "I don't get why this is a MeTa post instead of a comment in that thread."

It's constructed as a policy question and not an answer to a question.

hal_c_on writes "Bad gardening advice could fuck up your garden.
"Bad medical advice could fuck you up dead. "Its not about 'elitism', its about the stakes being higher...and they should be treated as such. Including advice in fields that aren't medicine and law."


Bad gardening advice could easily kill. For example: Castor beans are easy to grow and I'd bet are tasty in a three bean salad. Really it's hard to imagine any question that couldn't lead to potentially deadly advice. All you need is the Mind of a DM handing out a Wand of Wishing.
posted by Mitheral at 8:32 PM on March 15, 2011 [3 favorites]


Many pet owners would have no difficulty calculating the lbs to kilo ratio

Many more pet owners live in the parts of the world where kilos are the standard unit of measurement, and would find being hectored to provide measurements for the metric-illiterate who can't use a calculator to multiply and divide by 2.2 offensive.
posted by rodgerd at 8:37 PM on March 15, 2011


Dear AskMetafilter,

Is it still worth visiting my weird aunt in Wisconsin to get vet-grade ketamine? Also, how many worming pills do I have to take if I just want to get mellow?
posted by klangklangston at 9:06 PM on March 15, 2011 [3 favorites]


At the risk of a derail, a few reflections

I miss Owsley too.
posted by jessamyn (staff) at 10:08 PM on March 15, 2011 [2 favorites]


Man, there's some bad advice about LSD dosages in that previous thread.
...
Conclusion. YOU CAN NEVER TELL WHAT YOU'RE GETTING just by looking at it.


Huh? I thought I covered that pretty well. If you haven't previously dropped off that same strip/sheet/book/dropper whatever, then it isn't known concentration.
posted by juv3nal at 1:38 AM on March 16, 2011


Ah, phillip_random, this is why I love metafilter.

And why I go to meetups with such hope in my heart.
posted by NoraReed at 4:08 AM on March 16, 2011 [1 favorite]


Bad advice can save your life, sometimes.
posted by Obscure Reference at 5:04 AM on March 16, 2011


That matches my observational experience, phillip_random. (I was the token straight that got everyone home safe from their parties in college. I guess everyone needs a friend who they know will be sober and nonjudgmental at 3am.) Every now and then I feel like I missed something by skipping the pharmaceutical experimentation phase. Then I realize that my brain chemistry messes itself up, all on its own, and figure it was probably wise. (It turns out that, in high school, several of my classmates thought I was boosting a bit, and were baffled because they knew everyone in town who sold that stuff and knew I didn't hang out with them. None of them ever quite got up the nerve to ask who my supplier was, though. I'm not sure they would have taken 'my own messed up brain' as an answer.)
posted by Karmakaze at 6:48 AM on March 16, 2011 [2 favorites]


People adding cautionary information to a thread is absolutely okay. Flagging is usually something for when you want a mod to take a look at something. In this case, there's not really much we'd do. You'd be much better off emailing/MeMailing the OP or, preferably, adding a note to the thread.

Repeated, repeated. There is a lot of information on the internet, and a lot of it is bad. There is a lot of information on MetaFilter, and a lot of it is bad. People who go on the internet for information are going to encounter the full range of information available, good and bad. It's quite possible that people will encounter bad information and act on it. That also happened before the internet, in real life, when general ignorance was even more facilitated because there were fewer easily accessed resources.

MetaFilter does offer a platform in which any registered user can post a response regardless of their knowledge, guaranteeing that in all kinds of threads, some bad information will appear. But because there's no way for MetaFilter to implement some kind of system which discriminates amongst the qualifications and knowledge bases of its many users to establish special commentators on any given topic, the only way to prevent bad information being offered is to stop the flow of comments. I think there is greater harm in that choice, because the MetaFilter community stands a much better chance of pointing a user in a useful direction than almost any other forum or search engine on the web that someone in need might use. Some bad information will appear, but it's very likely the cautionary voices that reinforce the "see your own professional" message will appear at one or more points in a thread. The more strongly stated, the better.

In past conversations on this topic, I've supported this pragmatic approach: People are going to pursue answers to their questions, and we can help be sure they are helpful and not harmful answers - something that is a collective, not a moderator, responsibility. The best counter to a lot of bad information is to add more good information, alerting the OP (and the many lurkers!) to serious considerations that may have escaped others in the thread. You don't have to give your bona fides, as I understand that is a conflict for some professionals, but you can certainly say "whoa whoa whoa, before doing anything, this is potentially very serious, so consult your professionals." Anyone able to do that, who does so, is keeping things on the rails here. Though there is no way to prove this, I believe that allowing these questions and answers, good and bad, prevents more harm than not allowing them on AskMetaFilter at all and leaving people to the resources of less well informed and committed communities.
posted by Miko at 6:57 AM on March 16, 2011 [1 favorite]


But because there's no way for MetaFilter to implement some kind of system which discriminates amongst the qualifications and knowledge bases of its many users to establish special commentators on any given topic, the only way to prevent bad information being offered is to stop the flow of comments.

In some cases, specifically law and medicine, the problem isn't discriminating qualifications. But because there's no way for MetaFilter to implement some kind of system which discriminates amongst the qualifications and knowledge bases of its many users to establish special commentators on any given topic, the only way to prevent bad information being offered is to stop the flow of comments. The concern is that good information about a specific problem (as opposed to general information, which is fine) cannot be obtained through this sort of forum. You just can't give good advice for a specific question based on a few paragraphs in an askMe. Appointing special commentators wouldn't solve that problem. You just can't get there from here without putting your license at risk (whether you disclose that you have a license or not), and the poster's health, liberty, or fortune at risk.

Honest to god, "Go to a doctor" and "Go to a lawyer" are often the only right answers, with everything else unethical or uninformed.
posted by Marty Marx at 9:09 AM on March 16, 2011


Whoops. Double quoted you, there. Ignore the second "But because" to "flow of comments."
posted by Marty Marx at 9:11 AM on March 16, 2011


In some cases, specifically law and medicine, the problem isn't discriminating qualifications.

Well, I think it is - especially in medicine, where there is plenty of legitimate disagreement on some issues (many issues, really...I know enough people in involved, extended treatments which involve multi-doctor disagreement to realize this). Just because someone has credentials doesn't mean they will always give 100% ideal advisement for any specific individual, online or in real life.

But I do agree with your more general point that the issue for professionals is that no one can diagnose anyone over the web. They can only indicate possibilities and generalities, and IMO that is the only thing a licensed professional ever should do online. In other words, they should never ever attempt to use their authority to imply that they specifically know what to do in an individual case, where they don't know the person's details intimately. It seems to me that where individuals have experienced problems with this, it is in not being careful to draw that clear boundary in their comments and their involvements with others they know only from the web, not from an office visit.

It can be really helpful, though, to have someone with professional training say things like "I am a doctor and it sounds like in the history you have related, your doctor hasn't explored with the possibility of X, which can cause results similar to what you are experiencing. Ask your doctor to explore X. I'm not saying that X is an issue for you, as there are many things that cause it, but X is definitely something to ask about ruling out."

Honest to god, "Go to a doctor" and "Go to a lawyer" are often the only right answers, with everything else unethical or uninformed.

This may be so in some cases, which is exactly why I think that answer should always appear in the thread as a caveat, and it does almost 100% of the time, which should really solve the concern.

But I'd add that in real life experiences people are having in an ongoing way with doctors and lawyers, it is sometimes still helpful to hear from others who are not professionals about their treatment histories, personal experiences, tips for dealing with issues, things they've read or discovered and found helpful, recommendations, reflections on how the doctor's methods strike them as consumers of medicine, etc. There are many more dimensions of information besides diagnosis which AskMe can help provide. It seems legitimate to me to recognize those dimensions of real life experience, which, again, happen on and off the web - they happen around office lunch tables and in discussions with friends. The difference is that here, it's actually possible for a professional to stick their head right in now and then and say "As a professional, that's the kind of thing that sounds serious and you should see your doctor." That means there's a special kind of utililty to allowing the free discussion to happen - without this being a public forum with many voices involved and allowed, the chances of having sensible, knowledgeable voices chiming are drastically reduced.
posted by Miko at 9:40 AM on March 16, 2011 [5 favorites]


Never(Always) Put Salt In Your Eyes
posted by Alvy Ampersand at 10:58 AM on March 16, 2011


Quebec has really exceptionally strict regulations about what a non-licensed lawyer can do, all of which fully apply to law students. So McGill University has a Legal Information Clinic that provides legal information to members of the wider community. There's also some exceptionally good legal information available online, both from private organizations and the Quebec government. It's hard for me to imagine that that kind of thing couldn't be as useful to Askme participants as it is to all the various residents of Montreal that go to the clinic.

I would say it's often possible to provide legal information in a way that is both useful to askers and not problematic for answerers, regardless of their licensing status. For example, the information that not all clauses in a contract are enforceable even if the contract is written and signed, and that the enforceability can depend on local law and here is a link to the relevant statute and/or more information from a government or private source.

Of course anybody who's unsure about what they're allowed to say or not should err on the side of silence and attention should be paid to context and phrasing, but it's not fair to assert that there's nothing useful that any expert could (ethically or practically) contribute.
posted by Salamandrous at 11:38 AM on March 16, 2011 [1 favorite]


tl:dr, but:

it would help a lot if pain meds weren't tied to kidney destroying compounds, such that a minor errror on dosage for the main thing (pain) wouldn't lead to a major organ failure. Please separate intentions from paternalism thank you.
posted by yesster at 4:20 PM on March 16, 2011


it would help a lot if pain meds weren't tied to kidney destroying compounds, such that a minor errror on dosage for the main thing (pain) wouldn't lead to a major organ failure. Please separate intentions from paternalism thank you.

That argument ignores the synergistic effect of NSAIDs on opioids. Additionally, it takes a bit more than a minor dosage error to reach levels of renal/hepatotoxicity with the current formulations. You'd need to take twenty Lortab 10/500s to even come close to boxing your liver.
posted by The White Hat at 5:57 AM on March 17, 2011


The White Hat: " it takes a bit more than a minor dosage error to reach levels of renal/hepatotoxicity with the current formulations. You'd need to take twenty Lortab 10/500s to even come close to boxing your liver"

You're making several assumptions here. One is that you are dealing with an optimal, healthy liver not compromised by viral, parasitic, rheumatologic/hematologic, metabolic, drug/toxin, biochemical, structural or hydrostatic issues, excesses, or deficiencies impeding safe transit and metabolisation of the NSAID through the hepatocellular system before an oxidative cascade (either local or global) can emerge and begin to cause toxicity. The second is that renal compromise can be very idiosyncratic when it comes to NSAIDs, involving both hemodynamically-mediated failure and/or acute interstitial nephritis (sometimes with minimal change nephrotic syndrome or even membranous nephropathy). Acute renal failure can occur with any NSAID (usually within 30 days of first use at set dose). Chronic renal injury can occur as a consequence of long-term use and even manages to have its own moniker: analgesic nephropathy, which is a kind of renal papillary necrosis and chronic interstitial nephritis that used to account for up to 10% of ESRD cases in Europe and the US but is now much rarer since phenacetin use has declined dramatically. However, as you say, NSAIDs are often synergistic, and especially with other NSAIDs. The use of aspirin with simultaneous acetominophen/paracetemol is problematic, because on its own, APAP gets detoxified through conjugated to glutathione and with sufficient glutathione production in the renal papillary that's not a problem. However, when there's aspirin present, the salicylate metabolite can concentrate and use up the glutathione. There's therefore an increased probability that APAP's toxic metabolite quinoneimine will not find sufficient gluthathione, and instead kick off lipid oxidation, producing peroxides and tissue necrosis.

There are also rarer consequences of NSAID use, such as pulmonary infiltrates with eosinophilia, neutropenia, anti-platelet effects in people with already compromised platelet quantity or quality or on warfarin or similar, variable cardiovascular effects with possible exacerbation of CHF and MIs in people with existing heart disease, aseptic meningitis, psychosis and cognitive dysfunction, TEN/SJS or pseudoporphyria.

That's not to say, of course, that people shouldn't take NSAIDs. But tying them to opioids is a drug policy decision with sometimes unfortunate consequences given the population that come to rely on them and a common inability to regulate dosages appropriately ("20 tabs? Maybe just this once"). And regarding the topic of this thread, many people think of NSAIDs an innocuous and fundamentally harmless. They're not, they are a drug class, with varied and complicated risks and benefits like any other. if a non-licensed person advises another to take a substance which later proves harmful, then that's at the very least civil actionable with an outcome difficult to predict. However, if you advise a person to take a drug, and you are a licensed health care professional, then you are establishing a doctor-patient relationship and taking responsibility for any adverse outcomes should they follow your advice. And if you were licensed, and you accepted them as a patient and advised them to take a drug with a harmful outcome without doing due diligence then that's an legal action with a much more predictable result. I suspect the same holds true for vets.
posted by meehawl at 2:47 PM on March 17, 2011 [1 favorite]


I get that licensed professionals need to be careful about what they are indicating. The thing is, we need the licensed professionals to look out for themselves. They should be the ones with the keenest sense of what language and topics could pose trouble for them. What I wouldn't want to see is a situation where licensed professionals are asking the site - moderators, the rest of us chickens, whoever - to do that for them.

If you think you can't safely say "Take this drug," don't say it. Maybe you feel you are on safe ground saying "This drug exists and has been helpful for some patient with similar conditions." Maybe that is too close to a recommendation for you, and you'd rather say something like "Ask your doctor about taking this drug," which is how pharmaceutical companies weasel around this issue. Or maybe you are more comfortable yet one step more removed, as in "You should really take this question to your doctor; only your doctor is qualified to comment on drug therapies for your specific condition." Or maybe you want to say nothing at all, and leave it to the untrained masses to stumble across a reasonable answer, and hope someone says "See your doctor" at some point. The thing is, I just feel the community is very much unable to make these distinctions for any licensed professional, so we need those folks to look after themselves in that way.
posted by Miko at 4:27 PM on March 17, 2011


Yeeaaah, it was definitely a flameout. There was some rather sordid nastiness.

Maybe some people have a different misunderstanding of the metaphor but doesn't a "flameout" refer to a kind of abrupt extuingishing of flames? The flames being some kind of disruption or DRAMA!, and the putting out of the flame is a brusque announcement of intent to leave.

I don't believe a flameout describes the way ikkyu2 decided to leave. "Bow out" would be more apt.
posted by P.o.B. at 7:45 PM on March 17, 2011


doesn't a "flameout" refer to a kind of abrupt extuingishing of flames? The flames being some kind of disruption or DRAMA!, and the putting out of the flame is a brusque announcement of intent to leave.

I have no such understanding of "flameout" from my experience with the term since 1993 - it was already being used on BBSes in those very early years of the internet (because it was already a problem. Heh.). I don't think it implies anything specific about a brusque announcement (which I would say ikkyu2's departure was, anyway).

Though the word "flamemout" exists in the context of engine operations, as far as the word's usage on the web, I think it didn't arise specifically out of references to engine problems, but is instead mainly an outgrowth of the phenomena of "flaming" and "flame wars," and is applied when the ultimate result of a flame war is that one user burns out and stops participating. It's that end to participation which is the "flameout." Interestingly, even in the engine context a "flameout" refers not to going down in flames, but to losing combustion because a previously active flame is unable to burn evenly and is thus extinguished.
posted by Miko at 8:23 PM on March 17, 2011


which I would say ikkyu2's departure was, anyway

Hmmm. I didn't read it that way, but maybe I didn't get the whole gist of what happened.
posted by P.o.B. at 3:09 PM on March 18, 2011


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