Tuesday, 24 August 2010

Two weeks in.....

It's now been just over 2 weeks since I got my insulin pump.  It's been......challenging, exciting and also, I have to say, pretty tiring!!!

I have been able to be in constant contact with my DSN (Diabetes Specialist Nurse), Gill, which has been brilliant and really reassuring to know that theres an expert on the end of the phone who can help with problems and panics.  I have been texting Gill each morning (at her request) to let her know what my blood sugar levels have been over night and also to make suggestions as to what adjustments I think I should make. 

I have been testing my sugars between 6 and 10 times per day which is much much more than I ever did in the past but it's necessary so that you can see exactly what your blood sugars are doing according to your doses and according to how much and what food you have eaten.  It is important to keep accurate and detailed records of all of your blood sugar test results, exercise, what you eat and other things such as being ill so that your basal rates and bolus doses can be altered accurately.  With accurate records you can then see patterns start to emerge at certain times of the day and/or when you eat certain things so you can then make the necessary adjustments.

Frequent testing is also essential because an insulin pump only delivers fast acting insulin so you don't have any long acting insulin in your system as a back up, therefore, if insulin delivery gets interrupted whilst on an insulin pump your blood sugars can go dangerously high in a pretty short amount of time so you need to know what is going on so you can treat high blood sugar levels quickly.

To test whether my overnight basal rates are correct I have been getting up at midnight and 3.00 a.m. to test my blood sugars - hence being so tired at the moment.  My levels have still been fairly high in the mornings so that means I probably need more insulin overnight.

I have been having a lot more hypos since starting on my pump.  Hypos were virtually non-existent for me in the past but now I'm having at least one a day which isn't fun.  The lows seem to be mid afternoon and a couple of hours after my evening meal so now we need to work out whether it's my basal rates that are too high at those times of the day or whether it's my insulin to carbs ratio before lunch and before dinner that needs to be changed.

I've had a few panics and dramas like when I managed to put the infusion set in a stupid place (where a roll of fat creases over when I sit down - Yes, I know that's not a very attractive image I've just conjured up for you - Sorry!!) and it was really quite painful.  I persevered with it but then at work I bent over to pick something up and the infusion set popped right out of my stomach...... Aaaaaaggghhh, I almost had a heart attack and went into total panic!!!  Then I managed to replace the infusion set without filling the tubing first because I was in a panic and wasn't concentrating on what I was doing!!

Changing the infusion set and reservoir has been fairly easy so far (apart from the daft mistakes I mentioned above).  At the moment I'm following the user guide to the letter each time I do it and it's taking me about 15 to 20 minutes but I'm told that I'll soon have it down to about 5 minutes!!!

Not doing injections is fantastic and has also been quite strange.  For the 1st few days it was a struggle to remember not to jab myself and it felt like something was missing!!! But it hasn't taken me long to get used to it and appreciate the fact that not injecting after 19 years is absolutely amazing and I never want to go back!!!!!

I've enjoyed showing off my pump and explaining to people all about it and how it works.  A couple of people at work have asked me "Whats that in your pocket?" when they have seen the tubing and I've been really happy to show them and tell them all about it.  I will carry on rambling on about my new bit of kit for as long as people are interested and want to listen!!!

So far, going from injections to an insulin pump has felt a bit like a full time job at times, trying to keep up with what's going on with my sugars and what I need to do with the pump, counting carbs and then remembering what to do when I need to change the infusion set and insulin reservoir and I've felt like my brains been in meltdown but I know it will be all worth it.

One small thing I don't like about being on an insulin pump is that I now have to carry around a load of extra 'D' related stuff!!! Insulin pump kit = Glucose tablets, blood sugar testing kit and record diary, pen, carb counting books, blood ketone monitoring kit and/or urine ketone monitoring strips, spare insulin pen (for just in case there are problems with the pump), infusion set, reservoir, vial of insulin, antibacterial hand gel, spare AAA batteries, Glucagon injection (for use during a hypo when you are unable to swallow glucose tablets or glucogel) and snacks (such as cereal bars)......I think that's everything!! Obviously it's only a minor irritation but it certainly requires a huuuuuuge bag to carry it all around in....perfect excuse to buy a nice new bag if you ask me!!!!  :o)

I'd like to say a big thank you to everyone who has asked how I'm getting on, offered tips and advice and who has just been there to support me during the last 2 weeks.  I have to say that the people I have met in the Diabetic Online Community have helped me massively with the transition from injections to insulin pump and it certainly makes things a lot easier when you know there are people you can talk to online and ask what you may think are daft questions.  There are always people willing to offer advice and help which is invaluable!!!  THANK YOU!!!

Also, a huge thank you to my other half, Gareth, who has been fantastic.  He has been there every step of the way for me, been to every appointment with me, put up with my moods and frustrations and he continues to help me with getting to grips with the pump.....I couldn't have asked for a more supportive partner!!! THANK YOU!!!! x x x
Last but certainly not least, I want to thank my Mom for being there for me from the very start of my Diabetes journey.....it's not always been easy, especially the teenage years when I refused to fully acknowledge my Diabetes.  It's only now that I realise how awful this must have been for my Mom and what a nightmare it must have been for her when nothing she did or said would get through to me.  I hope now that I have taken hold of this condition and accepted responsibility for my Diabetes I can  make her proud of me.  Love you Mom and thank you so so much for everything!! x x x

So to conclude, 2 weeks in, do I prefer the pump to injections??? Of course I do!!!

Tuesday, 17 August 2010

New beginnings on the Insulin Pump

So, here goes......this is my first blog as an insulin pumper.....do I feel different?? Well, apart from sitting at the laptop now wearing my new permanent attachment, not really, but it's certainly been an interesting first few days!!!

MONDAY 9TH AUGUST 2010 - Awake bright and early due to happiness, excitement, fear, nervousness and anxiety all rolled into one.  Got up and did my last ever injection which I have to say was a pretty surreal and momentous occasion!!! It was a really strange feeling to be doing my last injection after just over nineteen years of doing them day in day out. Mixed emotions really as in a weird way, although they can be a pain to do and are sometimes painful (especially lately) the injections feel "safe" and reliable and you know for sure that the insulin has gone into your system whereas with a pump you are reliant on a machine to do the work for you and as we all know, machines can malfunction from time to time. (On the pump there might still be the odd occasion when I will need to inject, if the pump goes wrong for some reason, but this was my last "official" injection).
It felt a bit like I was standing on the edge of a cliff ready to jump off into the unknown because I still felt like there was SO much I didn't know about using an insulin pump. Obviously the day at the hospital was going to clear all of that up but before we set off I felt more than a little overwhelmed by everything I was still to learn and my new way of life.

My DSN, Gill, has been and continues to be fantastic and she made me feel at ease right from start of the day.  First of all we went through all the bits and pieces in the box and had a look at all the supplies and things that go with a new insulin pump.  Next we went through the menus on the pump.  Gareth got to do all of the same steps along with me because Gill let him use her spare demo pump so he could see exactly how to use a pump too which was really useful.  

We then looked at basal rates and how to set them.  The insulin pump mimics a normally functioning pancreas by delivering insulin continuously over 24 hour periods, this is your basal rate and accounts for around one half of your body's total daily insulin requirements.  Basal insulin is delivered at a rate of so many units per hour to cover your body's insulin requirements between meals and at night.  Basal rates can be reduced when you are going to do some exercise so that your blood sugar does not go too low and can be increased when you are ill to stop your sugar levels going too high.  The Medtronic Minimed Paradigm Veo allows you to set multiple basal rates for different times during a 24 hour period.  Gill had calculated that I would start on one unit per hour.  This would just be a starting point and it is likely that I will need to adjust them at certain times of the day until I get the dose I need to ensure that my blood sugar levels stay on target.

Next we looked at how to give bolus doses.  Bolus insulin doses are given on demand when you eat or to correct a high blood sugar level.  You work out the bolus dose you need according to the amount of carbohydrates you are going to eat.  My current insulin to carbohydrate ratio is 2 units to 10 grams of carbs so for example if I was going to eat 20 grams of carbs I would need to give myself 4 units of insulin.  Bolus doses are also used to correct a high blood sugar.  To work out how much insulin you need to take to bring your blood sugar back down to your target level you need to know your insulin sensitivity factor.  Gill had worked this out for me.  To bring my blood sugar down by 1.1 mmol I need to take 1 unit of insulin.

As you can see there are a fair few calculations involved in this insulin pump lark!!! Once you tell the pump your target blood sugar range, your insulin to carb ratio and your sensitivity factor then it can work everything out for you but at first Gill wanted me to work it all out on paper so that I fully understood the calculations and what they mean.  Once I had mastered this we could start to use a function called the Bolus Wizard which, like I said, works everything out for you.  We did a few practice calculations on paper then it was time to learn how to fill the reservoir with insulin and connect the infusion set.

There are several bits of kit you need to have in order to get the pump ready to connect to your body.....a vial of insulin, a reservoir and an infusion set.  The reservoir connects to the top of the vial of insulin and you draw back the plunger slowly to draw up the insulin into the reservoir.  You have to do this really slowly so that you don't get bubbles in the insulin.  If there are some bubbles you need to tap the reservoir to get rid of them. 

Once you have made sure that the pump is fully rewound you insert the reservoir into the pump and you need to fill the tubing with insulin.  This is all done by following the instructions on the pump screen.  Apologies if this is hard to follow, its quite hard to explain all of the steps involved without this being like a copy of War and Peace, especially as I can't actually show you what I'm typing about!!!!

You are then ready to connect the infusion set to your body.  The infusion sets I'm using are called Mio's.  It is important to make sure that the insertion site is clean and that you rotate the site you are using each time you change the infusion set, which should be every 2 to 3 days. 

The big moment........I was about to get connected!!!! I chose a site and fired the cannula into my stomach and 'hey presto', I was connected.  (Firing the cannula into my stomach sounds a bit drastic but I couldn't think of any other way to describe it - again, it's difficult to describe something when you can't see what I'm talking about).  Gill shook my hand and said "Congratulations, you are now an insulin pumper".....WOW!!! I could hardly believe it was happening and I didn't know quite what to say!!!!

Then I got to use my new blood glucose testing meter which tells the pump via bluetooth what your test results are....it's all very clever you know!!!  :o

I was then let loose on my own and we went to have lunch and I had to work out the carbs in my meal and work out how much insulin I needed.  Bit daunting but with the help of the calculator on my phone we managed to work it all out and away I went......I had given myself my first bolus dose on my pump!!!

The afternoon was spent discussing what to do if I had either high or low blood sugars and when to go back to injecting if there was a problem with the pump. 

I was due to go back to the hospital on Wednesday afternoon when I would learn how to use the Bolus Wizard and would do my first set change.  Gill wanted me to contact her at 6.00pm and 10.00pm to let her know how things were going which was a great reassurance for me as I felt like I had some back up if anything did go wrong.

My blood sugars over the next 24 hours were a bit up and down but that was to be expected until things settled down.  It had also been a pretty stressful/emotional day so that can sometimes affect sugar levels too. 

Gill let Gareth take home her spare demo pump so we could both have a look through the menus again and familiarise ourselves with them without actually doing anything on my "live" pump.  Once we got home I persuaded Gareth to get connected aswell so he could see what it was like for me.  I realise its not possible but I think it would be great if all hospitals could allow partners/spouses of Diabetics and parents of children with Diabetes to do this so they can get a real insight into what its like to wear one and also so that they have as much knowledge as possible about the pump and how it works.

All in all, a very successful day and the start of my new way of life.  I know its not going to happen overnight and that there is some hard work to go into getting doses right to ensure I hit my target blood sugars and bring my HbA1c down to where I want it to be but I am really positive about the future and I am looking forward to seeing the great results and improved quality of life I know my new insulin pump can bring.

Oh, and one more thing.....I have decided to name my new pump "Posy" - so here's to a long and happy relationship with my new best friend.....Posy Pump!!!!  :o)

Friday, 6 August 2010

Ten becomes Nine!!!!

I have just worked out that I have only TEN injections left to do before I go onto my insulin pump on Monday!! 

After 19 years of either 2 or 4 injections per day this is an amazing realisation.  Let's say I did approximately 10 years at 2 per day and 9 years at 4 per day, that's 20,548 injections since diagnosis so to think I now only have TEN left to do is mind boggling and very very exciting!!!!!! 

(Going onto the pump does not mean that I will never have to inject ever again, as there may be problems with the pump such as the tubing becoming clogged and I will have to keep spare injections for these instances)

Over the years when people have asked how I feel about injecting I have always said it doesn't really bother me that much, it's just something you get used to and at the end of the day it has to be done whether you like it or not. 

Lately though it has started to become really quite painful every time I inject and I've started to actually "think" about it before I put the needle in whereas I used to just stick it straight in (for want of a better phrase) without even thinking about it.  So now I think I would say that yes, injecting does bother me and for the first time in a long time it feels like a big deal to have to do it 4 times a day.  That's why the thought of just TEN more is so fantastic. 

Anyway, I'm off to do my Lantus, so that makes it just NINE more injections to do!!!!! :o)

Wednesday, 4 August 2010

Countdown to Connection

The 'Mio' Infusion Set for Medtronic MiniMed Paradigm Veo Insulin Pump
My insulin pump start date is getting closer and closer.....my overwhelming emotions in relation to this are obviously elation and excitement but I have to admit it......I'm also slightly nervous and scared.

I'm sure some people won't understand how I can be feeling anything but excitement about getting my pump, especially people who have had or are having a fight on their hands to get one.  I certainly don't want to annoy anyone by sounding ungrateful because that is not the case at all, I am extremely grateful for the opportunity I have been given and always will be.

It's hard to explain my feelings about Monday.....

I guess the word would be "apprehension".  There are a few things I feel a bit nervous about, one being the fact that I will be more or less permanently attached to something for the rest of my life....ok, so I got on fine with it during my 3 day trial at the weekend and I do know that you can disconnect for short periods of time, but I do feel a bit freaked out by the "alien" element of it all.  I have done a bit of reading on accepting being attached to the pump in my new "bible" (Pumping Insulin by John Walsh and Ruth Roberts).  It mentions that some people may feel embarassed or self conscious about wearing a pump.  I have to say that I am not concerned about that at all, in fact I am quite looking forward to telling people about it and explaining what it is and how it works, as it is certainly nothing to be ashamed of and I think the more people that know what it is and understand something about how it works the better.  It's not how it looks to other people that concerns me, I think for me it's the "attachment" element of it which is quite hard to put into words.  If anyone else had similar thoughts before starting on their pump please let me know.....(then again it might just be me!!! Lol)

Again, I do want to make it really clear that overall I am VERY happy about getting my pump and these negatives I'm talking about today are only small niggles, not major concerns!!!!  I think it would be difficult to do something so life changing without feeling some sort of nervousness or anxiety. 

I have been doing injections for 19 years now (first with a syringe and a glass vial of insulin that you had to draw up into the syringe yourself then with pens with cartridges that you changed and then finally with disposable, pre-filled pens) so I think I am going to find it really strange at first when I no longer have to reach for the insulin pen at set times of the day and for a while I might have to get Gareth to hide my pens so I don't inject!!! :o)

I started making changes in April by learning to carb count and work out insulin ratios according to the amount of carbs I am going to eat so the next step is to apply what I have learnt to the insulin pump.  I'm a bit nervous about managing to work out basal rates etc. but that will all be done with the help of my DSN on Monday and there will be plenty of ongoing support for me from her in the weeks and months to come.

Below are a few advantages and disadvantages of insulin pumps which must be considered before making a decision about whether a pump is right for you:
(Taken from http://www.input.me.uk/)

•Being attached to the pump almost all of the time (the pump can instantly be disconnected for brief periods " swimming, showers, sex, etc.)
•Risk of diabetic Ketoacidosis (DKA) may be higher without frequent blood glucose testing
•Chance of skin infections, especially if the infusion set is not changed after 3 days
•Offers a better quality of life and well being
•Freedom from a fixed insulin dose schedule
•Eat what you choose, when you like
•Ajust insulin to meet the body"s needs
•Feeling "normal"
•Being more alert & aware
•Being in control of life as well as diabetes
•Easier management of exercise, sport
•Reliable insulin action
•Staying up late, having a lie-in, or oversleeping without worry
•Restoration of hypoglycaemia awareness
•Managing the dawn phenomenon
•Travelling across time zones without missing or taking too much insulin
•Tight diabetes control before and during pregnancy
•Delay or prevention of long term complications
As you can see the advantages outnumber the disadvantage by far.....
Starting on the pump is going to be a massive life change, one which I am finally ready to accept. It's almost like throwing out everything I have ever known about Diabetes and starting all over again at the bottom of a pretty steep learning curve. I am so lucky to have been given the chance to make my way up to the top of the curve.
For years and years I just did the same doses with every meal, no matter what I was eating, no matter what exercise I did (if any) and I just did this without thinking about any of it. Starting with carb counting and going onto the pump has made me realise that it's not as straight forward as that if you want to take proper care of yourself. The next few months are going to be a lot of hard work in terms of more blood sugar testing, recording everything I eat and everything I do to see whether the basal rates are correct. I am totally ready to do everything I need to do to stay on the path of good Diabetic control for the first time ever!!!

As Monday gets closer I do have mixed emotions about getting "connected".....one minute I am high as a kite with excitement then I get a sudden surge of slight panic.  Then I think about the people I've got around me and I know that with their help and support I will be just fine and will soon get used to having my pump and, before I know it it will be as though it has always been a part of me........

Monday, 2 August 2010

What a Week It's Been!!!

Well, it's been a busy old week in terms of my Diabetes....

Last Wednesday was another session of laser treatment for Diabetic Retinopathy (which I did a huuuuuuge blog post on last week).  As usual, even though I have had quite a few sessions on both eyes in the last few years, I was terrified and got myself in a right old state beforehand.

Ever since the first time I had it done and I fainted I have had to have the anaesthetic injection in my eye before the laser session so I was quite prepared to have it done again, in fact, although it's not very nice and it involves them making a small cut in your eye ball, I would much rather have that than have to feel the pain / weird sensation that you get when your being lasered and risk fainting again so that they can't carry on and finish the session.  Anyway, the doctor, who I had never seen before (I hate they way it is a different doctor that does it every single time!!!) decided that she didn't want to give me the injection.  She said: "a lot of people tell me I'm very gentle with the laser" which didn't really make me feel any better but even though I said I really would prefer to have the injection she insisted that we would just "see how it went without it".....I was not happy at all and I started to panic even more.  To do the laser burns they have to shine an incredibly bright white light into your eye which always makes my other eye instinctively close, which then makes the eyeball that they are trying to laser move around....the doctor told me to try and keep my left eye open so that my right eye wouldn't move so I tried to explain to her that this is one of the reasons I always have the injection first so that it numbs my eye and it won't move during the lasering but all she said was "oh well".....Great!!

It didn't hurt too much for the first few burns but after about 5 minutes it got really sore and I started to feel faint and queasy so we had to stop....this happened another 2 times, by which point I was in a lot of pain (which can happen when you have had a lot of previous sessions) and felt very hot and sweaty and the room was spinning.  At this point she decided to stop.  I really did feel as though she hadn't done enough but knew that for her to carry on she would have to do the injection as I was in a lot of pain and she just did not want to do it.  I got the impression from the minute I walked in the room that she just couldn't be bothered doing the anaesthetic procedure for me.  I'm sure plenty of people can easily take the pain and discomfort of having it done but everyone is different and has a different pain threshold so I'm really not happy that she just fobbed me off and made me feel as though I was being pathetic!!!! Before she sent me off home she said "I've made a note that for your next  appointment you do need the anaesthetic doing first"......I do hate to say I told you so but....... 

Next time (31st August for my left eye) I am going to refuse to have it done unless they agree to give me the anaesthetic injection first and I do not want to see that same doctor again for laser treatment.

The next day was not nearly as horrible......it was my appointment at Stafford Hospital to start my insulin pump trial....how exciting!!! I was expecting to take 2 home for the weekend but when we got there we discussed the 2 types and decided that I would only take home the Medtronic pump.  We discussed how I had been getting on with the carb counting and how I had been feeling in general.  I have been having far less headaches than I used to, I am able to stay awake much later than I used to - I used to get in from work and could easily fall straight to sleep or go to bed at 8.00 pm because I was constantly exhausted and I have been having quite a few more hypos than I used to.  Before I went on holiday I had my HbA1c done and amazingly it had come down from 11.6 in March to.....wait for it......8.8!!!!!!! (For those not in the know already, the target they always tell you to aim for is 6.5 so I am getting there).  I am so pleased that it has come down by that much already.  I did expect it to have come down but not by that much (it might not sound like much but in terms of HbA1c results every 1% counts a hell of a lot).  This reduction would explain why I have been feeling less tired and been having less headaches.  See below for a description of what the HbA1c test actually is........

HbA1c Tests
The HbA1c test, indicates your blood glucose levels for the previous two to three months.  HbA1c (glycosylated haemoglobin) is a measure of the amount of glucose attached to the body’s red blood cells; it is present in everyone. The level of HbA1c in your body rises and falls in line with your blood glucose – the higher your HbA1c, the more glucose is attached to your red blood cells.   

Your HbA1c does not change rapidly because the red blood cells in your circulation last for around 3–4 months. Any increases and decreases in your HbA1c will happen over a period of at least 6 weeks. An HbA1c test is not the same as a blood glucose test. Your HbA1c test may be done using a blood sample taken from your arm or from a finger prick test.

HbA1c Targets
For most people with diabetes, the HbA1c target is below 6.5 per cent, since evidence shows that this can reduce the risk of developing diabetic complications, such as nerve damage, eye disease, kidney disease and heart disease.

Individuals at risk of severe hypoglycaemia should aim for an HbA1c of less than 7.5 per cent. However, any reduction in HbA1c levels (and therefore, any improvement in control), is still considered to have beneficial effects on the onset and progression of complications.

HbA1c Results
HbA1c results are currently given as a percentage. However, the way in which HbA1c results are reported in the UK is changing. From 31 May 2011, HbA1c will be given in millimoles per mol (mmol/mol) instead of as a percentage (%).  To help make this transition as easy as possible, all HbA1c results in the UK will be given in both percentage and mmol/mol from 1 June 2009 until 31 May 2011.

This new way of reporting results will just be a different way of expressing the same thing. For example, the equivalent of the HbA1c target of 6.5 per cent will be 48 mmol/mol. The fact that the number is higher does not mean there is more glucose in your blood.

So anyway, back to the pump trial....I had a quick practice with an infusion set for the Medtronic pump and then once we had had a look through the menus on the pump screen I was given all the bits of kit I needed to take home with me for the weekend.....infusion set, saline, alcohol wipe, infusion set inserter, the pump, reservoir for the insulin (saline for the trial) and off I went.

We decided to go to my Mom's to set up the pump and put in the infusion set so I could show her how it works (I was dying to show off my new "toy").  I had a bit of a 'faff' with drawing up the saline into the reservoir but after that it was all plain sailing and I did my very first insertion all on my own.  I was really surprised just how painless it was and then during the evening I was surprised that I managed to forget it was even there!!!!
Spending our first night sharing our bed with the pump was fine apart from me rolling on it a few times as the one I had on loan did not have a waistband clip on the back and I couldn't attach it to my PJ's.
On Friday I loved showing off the pump to people in my office and explaining all about it which has earned me the new nickname of "the bionic woman".
I had a bit of a play around with the menus over the weekend and gave myself "fake" doses of saline but that part of it (setting the basal rates etc. etc.) will be explained to me at the training on 9th August.
The only two minor "freak outs" I had were when I was in the shower and the pump was disconnected from the infusion set.....I knocked the infusion set a couple of times and for some reason that really made it hit home that I will have one of them in my stomach forever from now on.  For some weird reason I found it stranger to look at it when the pump was disconnected from the infusion set/my stomach and all that was left was the device lodged in my stomach...I'm not sure why this made me feel so strange but I guess it's just all part of getting used to this new "part of me" and my new way of life.
When I took the pump off on Sunday morning I immediately felt "lost" without it which I think must be a good sign as I must admit the part I had been mot worried about was getting used to being attached to something "alien" for the rest of my life so if I already feel lost without it that can only be a good indication that I will soon get used to that side of it all.
All in all the trial went really well, much smoother that I expected, and I am now really excited to get started on my own pump and start to learn all of the more 'technical' aspects of using the pump.  The trial was more about getting an idea of how it will feel to actually wear the pump. 
Today I contacted my DSN at the hospital to let her know that it went well and that I would like her to go ahead and order my (bubblegum pink) pump from Medtronic!!!!
I can't believe that this time next week I will be "connected" and I will be a member of the "insulin pumping community".  I am so grateful for all the help I have had from my DSN's at my GP's in getting me referred, from my dietician at the hospital, from my new consultant and from my new DSN at the hospital.  It has been a very short "journey" from injections to pump and I really do appreciate how lucky I am to have even got funding for a pump, let alone get one so quickly.
All that's left for me to do now is think of a name for my new pump :o)

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