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    "When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov

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    Friday, October 07, 2005

    Soldier On: The Cheerful Oncologist on the doctor's responsibility.

    posted by Sydney on 10/07/2005 11:22:00 PM 0 comments

    The Key to Happiness: Candy.
    posted by Sydney on 10/07/2005 11:18:00 PM 0 comments

    In the Mail II: From my accountant, regarding third quarter income tax payments mailed to the IRS in San Francisco:

    An accident occurred on the San Mateo Bridge near San Francisco in the early morning hours of September 11, as a contract courier was delivering mail from the post office to a check-processing facility in Hayward, California. The IRS estimates that approximately 30,000 of the estimated 45,000 tax payments on board the vehicle, mostly Form 1040-ES quarterly estimated tax payments, were ejected into the San Francisco Bay and are not recoverable.

    Someone cashed my check. Hope it was the IRS and not some lucky fisherman on the Bay.

    More here.
    posted by Sydney on 10/07/2005 11:03:00 PM 0 comments

    In the Mail: A letter from my state explaining that I will henceforth be taxed for the "privilege of doing business in Ohio." And I have to pay the state a "registration fee" just to tell them I'm eligible for the tax. So why don't I feel privileged?
    posted by Sydney on 10/07/2005 10:57:00 PM 0 comments

    Real Winners: Forget the Nobels. The . The prize in literature was especially deserved.
    posted by Sydney on 10/07/2005 10:55:00 PM 0 comments

    Fun with Chicken: Subway recently pulled an ad for their chicken cordon bleu sandwich because it was insulting to French expatriates. It had featured a chicken dressed as Napoleon.

    Napoleon was certainly no chicken, but there is such a thing as chicken Napoleon.

    And there's also this Napoleon-associated chicken.
    posted by Sydney on 10/07/2005 07:52:00 PM 0 comments

    The End of Paps? Will pap smears become obsolete? If this vaccine catches on, they might:

    An experimental vaccine against cervical cancer has cleared its final clinical hurdle, showing in a large trial of more than 12,000 women that it is 100 percent effective in blocking the major forms of the disease, its manufacturer said Thursday.

    Merck & Co. Inc. said it will seek Food and Drug Administration approval for the vaccine, called Gardasil, later this year and could begin marketing it in 2006. The vaccine immunizes against the human papilloma virus, or HPV, which is the primary cause of cervical cancer.

    If approved, the vaccine would most likely be administered to children 12 or younger -- before they become sexually active -- including boys, who can be carriers of the virus.

    The vaccine protects against a virus that has infected 20 million Americans and blocks a cancer that kills 3,900 American women each year. There is no treatment for HPV infection.

    Death rates are low in the United States because of widespread Pap screening, but worldwide, cervical cancer is the second-leading cause of cancer death in women, killing an estimated 250,000 each year.

    Will this become the next vaccine to be added to the childhood immunization schedule in the United States? Probably. Will anyone do a cost-effectiveness analysis before it's recommended for every female child? Probably not. We already give universal chickenpox vaccines to prevent about 200 deaths a year. We have an aversion to such stuff.

    UPDATE: Another side of the coin, from a reader:

    The medicine is great, but what about the moral issue? Do we tell kids that with this, and other shots, the risk of disease is lessened so grab a condom and go at it? Pregnant? Have an abortion and we can harvest the fetal cells.

    Teenage births are going down, but we still have a large number of single family homes and as a society we deal with the income, supervision, and other family issues that arise in these situations.

    We think everyone is putting forward a responsible message until your friends 20 year old daughter has to defend her choice not to have sex at a school mandated physical. The doctor suggested counseling since she should be sexually active and would benefit from the experience. The fact that her older sister had an out of wedlock child, and she has felt the repercussions, did not enter into the doctor's thinking.

    That old unintended consequences issue raises it's ugly head again.

    Well, that doctor could use some cultural competency training. (Oh, wait. Cultural competency only counts for different ethnic groups, not different cultural values.)

    All snarkiness aside, the threat of sexually transmitted disease - even fatal, incurable ones - does little to dissuade careless sex. Like smoking and lung disease, there's a disturbing tendency to think it won't happen to you. The power of denial should never be underestimated.

    Nor should the influence of culture on behavior. Giving the anti-HPV vaccine to children isn't going to encourage them to have sex at an early age. Giving them a pack of condoms and a Sex and the City DVD box set will, though.
    posted by Sydney on 10/07/2005 01:17:00 PM 0 comments

    Thursday, October 06, 2005

    Pharma Terrorists: New York City's terror alert was spurred by captured terrorist pharmacists:

    According to sources in intelligence, emergency services and police headquarters, the intelligence community developed information that the threat may have involved pharmacists from Iraq coming to New York for some kind of chemical attack targeting the subways.

    Three insurgents, one or more of whom are pharmacists, were arrested during a raid by a U.S. military and intelligence community team, sources said, and one of those caught disclosed the threat. Because it slipped out during the arrest, the plot was deemed credible.

    (via Confederate Yankee.)

    posted by Sydney on 10/06/2005 09:13:00 PM 0 comments

    Cool Band-Aids: When I told my husband about these his eyes lit up and he asked me to buy some.
    posted by Sydney on 10/06/2005 09:09:00 AM 0 comments

    Speaking of Eyes: Watch out for computer vision syndrome.
    posted by Sydney on 10/06/2005 09:04:00 AM 0 comments

    Medical Mystery Time: The case of the blue and brown-eyed child.
    posted by Sydney on 10/06/2005 08:54:00 AM 0 comments

    The Resurrection: While government health officials have been busily wringing their hands that the avian flu might mutate into a flu virus as dangerous as the 1918 Spanish flu virus, they've gone and gone and resurrected the original killer. But don't worry, they've things under control:

    The scientists involved in the project contend there's no real risk to public safety. The vials of this frightening germ -- about 10 of them -- are locked away at the federal Centers for Disease Control and Prevention in Atlanta, said Terrence Tumpey, the CDC research scientist who constructed the virus.

    ...The reason the scientists believe their reconstructed virus poses no public health threat is that based on previous research, modern-day medicines are effective against the 1918 flu. And they think most people today are already at least partially immune.

    The subtype of virus that caused the 1918 pandemic is now common, and so it would not be as unknown to the immune defense systems of people today. In other words, it would not be as deadly, said Adolfo Garcia-Sastre, microbiologist at the Mount Sinai School of Medicine in New York.

    ``In each pandemic, it's been a new subtype of virus,'' not an existing one, said Garcia-Sastre, who participated in the effort to reconstruct the virus.

    Can you say hubris? The virus they resurrected is not an existing one, either. It mutated itself out of existence after the epidemic. That's why they had to reconstruct it. And our modern day medicines aren't completely effective. They aren't curative, they just slow the influenza virus down a bit.

    P.S. Now we know why the CDC hasn't been sharing its data.

    posted by Sydney on 10/06/2005 08:52:00 AM 0 comments

    Big Brother Hoosier: Indiana's state legislature is thinking about limiting assisted reproduction to married folks:

    An interim legislative committee is considering a bill that would prohibit gays, lesbians and single people in Indiana from using medical science to assist them in having a child.

    Sen. Patricia Miller (R-Indianapolis) said state law does not have regulations on assisted reproduction and should have similar requirements to adoption in Indiana.

    If the intent is to limit the number of procedures the state has to pay for, it's a little more understandable. But, the intent appears to be to legislate morality. No one can predict who will be a good parent. Marital status or heterosexuality certainly aren't gold standards. Maybe what Indiana really needs to do is loosen up its adoption standards.

    UPDATE: The bill's been withdrawn.
    posted by Sydney on 10/06/2005 08:31:00 AM 0 comments

    Breast Cancer Interactive: It's Breast Cancer Awareness Month. Here's a video about the anatomy of breast cancer (click on the link under "Quick Links" on the right side of the page), and here's a how-to video on breast self exams.
    posted by Sydney on 10/06/2005 08:19:00 AM 0 comments

    Wednesday, October 05, 2005

    Dashed Dreams: Some disappointed dieters are suing Dr. Phil. It's surprising suits against fad diets and supplements don't occur more often.

    posted by Sydney on 10/05/2005 06:27:00 PM 0 comments

    Science Blogging: The Tangled Bank is up.
    posted by Sydney on 10/05/2005 06:25:00 PM 0 comments

    Nasal Irrigation: No Watermelons Allowed emails to ask what I think of Neti Pots:

    The practice of nasal irrigation, known as Neti, has been used by practitioners of Yoga and Ayurveda in India for hundreds, if not thousands of years. Neti is one of the six purification techniques undertaken prior to the practice of yoga to help prepare the body for the yoga practice. It is referred to in the original yogic texts known as the Hatha Yoga Pradipika and the Gheranda Samhita. It is described at some length in the Complete Illustrated Book of Yoga by Swami Vishnu Devananda, published in the USA as early as 1960. Some yogic teachers consider it valuable in cleansing the energy channels and balancing the right and left hemispheres to create radiant, energetic health and wellness, which is the foundation upon which true yogic practice can come to fruition.

    While there are advanced techniques using various herbs and herbal oils, the simplest technique, known as "jala neti" uses water (jala) for the cleansing process. Lukewarm water is used to gently open up the nasal passages. Use of a neti pot or vessel is recommended to ease this process. Advanced practitioners may use this pot also for the herbal or oil administration (referred to as "nasya") as well.

    To tell you the truth, this is the first I've heard of the practice. Irrigating the sinuses with a water solution is probably OK, as long as it isn't done with too much force, (I often recommend a salt water nasal spray for sinus sufferers, and otolaryngologists sometimes irrigate them in their offices) flushing the sinuses with herbs and oils wouldn't be prudent. Our body cavities aren't designed to handle oils and herbs. It seems like a perfect set-up for worsening inflammation.

    UPDATE: From an ENT:

    When otolaryngologists "irrigate the sinuses" it is done by performing a needle puncture into the sinus, or sometimes when possible by cannulating the middle meatus. Your post seems to confuse the sinuses with the nasal passage, which is what I would expect of a lay person, but not of a doctor. I suppose there are a few old timers around who still perform the Proetz maneuver in their offices (which is a form of nasal irrigation), but I haven't seen nor heard of one for more than thirty years. As to nasal irrigation, IMHO, it is highly overrrated except as adjunctive therapy during proven sinus infections and is in the same category as high colonic therapy.
    posted by Sydney on 10/05/2005 08:05:00 AM 0 comments

    Tuesday, October 04, 2005

    Grand Rounds: Is in session

    posted by Sydney on 10/04/2005 08:56:00 PM 0 comments

    Enter at Own Risk: Tourists to Florida are being warned that their lives may be in danger as they get off the airplane:

    A national gun-control group is riling Gov. Jeb Bush and Florida's mighty tourism industry by warning visitors that arguing with locals here could get them shot.

    The group, the Brady Campaign to Prevent Gun Violence, based in Washington, began handing out fliers at Miami International Airport on Monday, cautioning visitors to take 'sensible precautions' and to be aware that altercations on highways, in nightclubs or on the beach could provoke a shooting.

    They've been Independent Online Edition >running warning ads in England, too, but I think the English already think of us as gun crazy, thanks to Hollywood.

    It calls to mind an experience I once had with four Irish youths. It was the late 1980's, the age of Rambo and Arnold. My husband and I were making a tour of Ireland, when our rental car broke down. My husband went to look for a phone and I stayed behind with the car. He didn't go far, just across the street to what looked to be a train station, but while he was gone, four boys who looked to be in their late teens or early twenties sauntered up to admire the car (It was a Honda. Wouldn't have gotten a second glance here in the States.) As they formed a semicircle around me, I suddenly realized the vulnerability of my position. I was out of the line of site of the train station, there was no other building or person in site, and the car was near what looked to be a junk yard. To top it off, before leaving for Ireland, I had read The Whore Mother, a novel of the IRA which portrayed every Irish male as a violent, heartless thug, and a short story in which the main character was raped while visiting Ireland. While my imagination was running amuk, the boys (they really were boys), asked where I was from.

    "New York."

    They must have jumped back four feet, while they all said at once - "New York! They shoot people there!" And off they went, leaving me alone and unharmed.

    They never knew I meant Syracuse.
    posted by Sydney on 10/04/2005 05:00:00 PM 0 comments

    Secrets of the CDC: Influenza researchers accuse the CDC of data hoarding:

    In its Sept. 22 issue, the journal Nature reported widespread concern among influenza researchers that too little flu data collected by the CDC are being made available for research, hindering their efforts to develop flu vaccines.

    Dr. Nancy J. Cox, chief of CDC's influenza branch, said the increasing focus on influenza worldwide has brought a deluge of requests for information that the CDC cannot easily accommodate.

    'Given the sheer volume of such requests, we have had to make hard choices about how to respond because we do not have the capacity to comply with all requests while also meeting our other public health responsibilities,' she said in a written response to questions.

    One unnamed National Institutes of Health researcher told Nature that, other than the occasional large deposits of data required by journals to accompany published papers, information from CDC is 'coming through an eye dropper.'

    Influenza researchers said their work would progress faster if they could access the disease control agency's databases of virus sequences and immunological and epidemiological data.

    Nature quoted Michael Deem, a physicist at Rice University in Houston, as saying: 'Many in the influenza field are displeased with the CDC's practice of refusing to deposit sequences of most of the strains that they sequence.'

    Nature's own analyses found that the CDC deposited less than a tenth of the 15,000 influenza A sequences in the gene database Genbank and the influenza sequence database at the Los Alamos National Laboratory in New Mexico. By comparison, a consortium led by the U.S. National Institute of Allergy and Infectious Diseases deposited more than 2,800 sequences this year alone.
    posted by Sydney on 10/04/2005 02:28:00 PM 0 comments

    Inching Closer to the I-Bod: Kinetic video games.
    posted by Sydney on 10/04/2005 02:20:00 PM 0 comments

    Playing the Sympathy Card: A nurse in England has successfully petitioned her local primary care trust to pay for her cancer treatment, even though, as a rule, they don't cover it in patients in her stage of illness. Why did they bend the rules? She's a mom:

    After a meeting with her, the trust has now decided to allow Ms Clark to have the drug on the NHS.

    The trust's chief executive, Alan Carpenter, said: 'The PCT has looked very carefully at Ms Clark's circumstances and believes it is in her best interests to receive Herceptin at this stage of her treatment.'

    Ms Clark told the BBC she was delighted with the news.

    She said: 'Because I've got exceptional needs, because I've got a child with a life-limiting condition, they felt it was extremely difficult for me.

    'He (her child) has nowhere else to go and no family of his own, so they thought it was an exceptional circumstance.'

    Good for her that she was able to convince the trust to finance a promising therapy, but does this mean they are going to enter the business of deciding whose life is more worthy? Sure seems like it.

    UPDATE: This post was the last straw for a long time reader and email correspondent:

    If you were truly speaking from a position of strength and excellence that would be one thing--but you know and I know that our health care delivery and financing system is the best in the world for some of us and dismal failure for others--all to often it breaks the heart, spirit and purse.

    I will be living in the UK next year while consulting with one of the regional NHS Trusts--there is absolutely no question regarding our technological superiority but I can tell you with certainty that they clearly have done a better job with compassion, equal access to essential psychiatric services and the provision of real support rather than tired rhetoric--I don't know about your practice but every day I see the best and worst of our system--Also, as an employer the premiums we are paying are obscene--until the following dynamics change we are not in a position to jab, knock or compare--
    --a dismal and almost useless public health system,
    --the financing of the public and private system is falling on way to few people--the essential reliance on employer based financing is increasingly an economic, policy and moral failure
    --We need tort reform--we need to practice medicine not law
    --There should be ongoing State based pilots of alternative financing strategies including variations on single payor systems--the administrative overhead in our system is embarrassing--20% +--give me a break and the list goes on

    Sorry for the rant but for me enough is enough--with warmth and regards but no more time for snarky comments.

    The post wasn't meant to slam the British system, and it certainly wasn't "snarky." It raises an important issue about the rational rationing of healthcare. It's wrong to deny a treatment to someone who is single but to pay for it for someone who is a parent, regardles of the healthcare system.

    Of course there are problems with our system, but unlike my correspondent, I don't believe the British and Canadian systems are superior. Neither do a lot of their citizens.
    posted by Sydney on 10/04/2005 02:03:00 PM 0 comments

    Dr. DJ: An unexpected role for anesthesiologists.
    posted by Sydney on 10/04/2005 01:41:00 PM 0 comments

    Ontario Mystery Virus: A Toronto nursing home has had a bad run of illness:

    So far six residents of the Seven Oaks Home for the Aged in Scarborough have succumbed to the unidentified illness, with the two most recent deaths having occurred Sunday night. But officials say the situation is improving as many of the 68 affected residents and eight employees are showing signs of improvement.

    "It appears to be winding down," said Dr. David McKeown, Toronto's medical officer of health. "We are seeing the illness take its course in those who are already infected, which is why we're seeing some additional hospitalizations and these two new deaths. But at this time many of those who have been affected are improving."

    Since the outbreak began Sept. 25:

    * 6 people are dead
    * 68 residents are sick
    * 8 employees are sick
    * 3 visitors are sick
    * 30 of 68 residents of Seven Oaks have been admitted to area hospitals

    Although the illness hasn't been identified, officials have ruled out the deadly Severe Acute Respiratory Syndrome, better known as SARS, as well as influenza and the avian flu.

    Nursing home patients are extremely frail. Even a virus as normally benign as a cold can be devastating for them, although having to transfer almost half the residents to a hospital seems unusual.

    UPDATE: Mystery solved. It was Legionairre's disease.
    posted by Sydney on 10/04/2005 07:59:00 AM 0 comments

    Tending the Psyche: It's Mental Health Awareness Week. I'll keep that in mind as I try to complete my yearly online family medicine board exam module.
    posted by Sydney on 10/04/2005 07:53:00 AM 0 comments

    Monday, October 03, 2005

    Crafty Drug Companies: Getting around spam filters.

    posted by Sydney on 10/03/2005 08:05:00 AM 0 comments

    Sunday, October 02, 2005

    Careful What You Wish For: The British version of the FDA, called Nice, is coming under fire for taking too long to approve drugs. They're taking the criticism to heart:

    Andrew Dillon, chief executive of Nice, said his institute was planning to speed up evaluation of new cancer drugs.

    "We have listened to what patients and healthcare professionals have told us about the need for timely advice on the use of new medicines, particularly for life-threatening conditions such as cancer," he said.

    “We have responded by proposing a new streamlined process for drugs, and we think these proposals can make a real difference.”

    Careful. That's what has gotten our FDA - and pharmaceutical companies - in so much trouble these past several years, rushing drugs into approval before adequately testing for side effects.

    posted by Sydney on 10/02/2005 08:40:00 AM 0 comments

    Saturday, October 01, 2005

    When Vaccines Bite Back: Earlier this year, the new meningitis vaccine, Menactra, became the latest addition to the childhood immunization schedule. It was recommended for 11-12 year olds, not because they have a high rate of meningococcal meningitis, but because health officials thought it would be a good way to get the kids in to see the doctor:

    CDC's Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination of young adolescents (defined in this report as persons aged 11--12 years) with MCV4 at the preadolescent health-care visit (at age 11--12 years). Introducing a recommendation for MCV4 vaccination among young adolescents might strengthen the role of the preadolescent visit and have a positive effect on vaccine coverage among adolescents.

    There were better reasons than suggested by that report. According to The Medical Letter, the number of cases of meningococcal meningitis in the United Kingdom declined from 67 to 5 within a year of vaccinating 80% of children under 18. The number of cases remained the same in unvaccinated age groups, so the strategy of vaccinating younger children rather than waiting until they go to college makes some sense, if your goal is to eliminate as much disease as possible the American way - without regard to cost. (The vaccine is $80 per dose)

    But now, the FDA is investigating potential serious side effects of the vaccine:

    The government is investigating five reports of teenagers who came down with a serious neurological disorder after receiving a new vaccine against meningitis.

    ....The five cases reported two to four weeks after Menactra vaccination occurred in 17- or 18-year-olds in New York, Ohio, Pennsylvania and New Jersey, FDA said. All are reported to be recovering.

    Studies of more than 7,000 Menactra recipients by manufacturer Sanofi-Pasteur showed no GBS
    [Guillian-Barre Syndrome - see above link - ed.] cases, and more than 2.5 million doses have been administered since it hit the market, FDA said. The rate of GBS is similar to what is expected without vaccination, but the timing of the cases is of concern and warrants further investigations, FDA said.

    Five cases out of 2.5 million doses is quite small, especially compared to the number of cases of meningitis:

    While there are fewer than 3,000 cases of invasive meningococcal meningitis each year, and 300 deaths, people ages 15 to 24 have the highest mortality rates, and survivors can suffer mental disabilities, hearing loss and paralysis.

    However, the disease incidence is higher in those under 1 years old and ages 18-24 than it is in the 11-12 year age group. Furthermore, the duration of the vaccine's effectiveness is not known, which means these pre-adolescents may end up needing boosters before they go off to college - when they'll be at a higher risk of catching the disease.

    So, while the number of Guillian-Barre cases may seem quite low, so is the incidence of meningococcal disease in the group getting the shots. The vaccine needs to be scrutinized a little more before it's given to every child in the country.

    posted by Sydney on 10/01/2005 01:14:00 PM 0 comments

    Stopping the Nagins: The World Health Organization did the right thing yesterday by stepping up to reign in the hysteria of the UN's avian flu coordinator:

    The health organization, a United Nations agency, was deluged with inquiries after Dr. David Nabarro, who was appointed Thursday as the United Nations coordinator for avian and human influenza, cited the 150 million estimate during a news conference.

    While the health organization's flu spokesman at its Geneva headquarters did not say the estimate was wrong, he said 7.4 million deaths would be more realistic. Scientists have made predictions ranging from fewer than 2 million to 360 million. Last year the health organization's chief for the Asia-Pacific region predicted 100 million deaths, but until now that was the highest figure publicly mentioned by one of the organization's officials.

    "We're not going to know how lethal the next pandemic is going to be until the pandemic begins," the Geneva spokesman, Dick Thompson, said Friday. "You could pick almost any number" until then, he said, adding that the organization "can't be dragged into further scare-mongering."

    Exactly so.
    posted by Sydney on 10/01/2005 01:07:00 PM 0 comments

    Flexible Spending Accounts: Are very flexible. They even summer camp and dance lessons and fancy vaseline.
    posted by Sydney on 10/01/2005 01:04:00 PM 0 comments

    Role Models Wanted: According to this Wall Street Journal article, we still lack good medical role models:

    In the past few years, there has been a movement to add courses on professionalism, empathy and communication skills. But there is mounting evidence that the new curriculum hasn't been effective. Paul Haidet, a professor at Baylor College of Medicine and an internist at the Houston VA Medical Center, has helped measure such efforts at 10 medical schools and says his surveys show the coursework is routinely undermined by what students see watching doctors in action.

    But how do you change grown person's personality, aside from some religious epiphany?

    Dartmouth Medical School has a new Web-based system called Dartmouth Medical Encounter System where students enter their experiences and encounters with patients to show how they meet the six ACGME competencies. It has created three societies that students join, which pair students with mentors to promote "some hard-to-get-at material, like professionalism, the privileges and obligations that come with it," says Joseph O'Donnell, an oncologist and senior advising dean at Dartmouth Medical School.

    At Southern Illinois University Medical School, an "Empathy 101" course asks students to share vignettes and poems about showing and feeling empathy toward patients.

    To train more caring, compassionate doctors, Indiana has developed a "Relationship-Centered Care" program that includes changing behavior of faculty doctors to act as better role models. Seven other medical schools recently spent a week on its campus to learn how to adapt some of its lessons for their own programs, in part to prepare to meet new ACGME requirements.

    How does that go over?

    Some students and faculty did initially resist, worried that sitting around discussing self-awareness and "role recognition" was all a waste of time in their busy lives. "It can all sound very Pollyanna-ish, as if we are all sitting in a circle holding hands and singing 'Kumbaya,' " says Richard Frankel, a medical sociologist and professor at Indiana. "But once they experience it they change their minds."

    I remain skeptical, but I wish them luck.
    posted by Sydney on 10/01/2005 12:53:00 PM 0 comments

    Stating the Obvious: To More Inmates, Life Term Means Dying Behind Bars. It wouldn't be a life term if they died elsewhere, would it?
    posted by Sydney on 10/01/2005 12:50:00 PM 0 comments

    Reading with Judith: Miss Manners' reading list. I second the The Golden Bowl. It's a very difficult slog through all the subtle communication between the characters, but well worth the effort. I read it recently, and found it hard to put down even though I often had to read things two or three times ot understand. Somehow, he manages to make a simple touch seem very sexy.
    posted by Sydney on 10/01/2005 12:50:00 PM 0 comments

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