#wwami

[phawareglobal]

Lia Barros, NP - phaware® interview 452

Lia Barros, a nurse practitioner at the University of Washington, discusses the role of nurse practitioners in caring for patients with pulmonary hypertension. She emphasizes the importance of nurse practitioners in meeting the unique needs of patients with pulmonary hypertension and suggests that adopting collaborative care models can improve patient outcomes.

My name is Lia Barros and I'm a nurse practitioner at the University of Washington in the Pulmonary Vascular Disease Program. I wanted to talk to you today about the role of nurse practitioners in caring for patients who are living with pulmonary hypertension.  I think first we can start with what is the history of nurse practitioners? The first school started in 1965, and it was really to address the shortage of providers for pediatric care. I think we can see that over the several decades since then, the role of nurse practitioners has really grown and is flourishing. Now, you can see nurse practitioners working in the primary care setting, in specialty clinics like pulmonary vascular disease, inside hospitals as acute care providers. So that's anything from the intensive care unit to the general floor. They have a wide variety of practice, and therefore there's a wide variety of models on how to utilize nurse practitioners and their skillsets. I always like to take a minute and also talk about what is the background of a nurse practitioner? I think that's one of the most common questions I get, even from other healthcare providers, is what is the unique role of a nurse practitioner, or what is the difference between nurse practitioners and physicians or physician assistants? A nurse practitioner is an individual who had to obtain a bachelor's degree and become a registered nurse. Many of us have practiced as registered nurses across a variety of spaces before deciding to go for advanced education. Then in order to become a nurse practitioner, you have to obtain, there's two ways, either a master's in science in nursing or a doctorate of nursing practice. Then, once you obtain that education, of course you sit for a national license. Some people then say, "Well, how come my nurse practitioner in one area or another seems to practice differently?" I think that's an important thing that we talk about, because we have a full extent of our license, but that license is then regulated state by state. I'm so blessed in the state of Washington, we allow nurse practitioners to practice to the full extent of their license. We receive training and diagnosis treatment, health prevention, advanced communication, and advanced patient education. I'm really allowed to utilize all of that in my practice. You'll see state by state that that varies. I'll speak to in the WWAMI region and in the state of Washington, because that is what I know. Nurse practitioners in this space are independent, licensed providers. So in the state of Washington, I'm allowed to practice on my own. That becomes really important when we think about the practice model. I do want to take some time to talk about that as well or share with you about that. When we think about nurse practitioners in the role of caring for patients with pulmonary hypertension, we really don't have a consensus. So when you look across the nation, there's really no consensus or agreement on how to utilize this expert for best patient outcomes. What we do know comes from literature looking at nurse practitioners in the primary care setting, as well as there's some literature out there looking at nurse practitioners in cardiology. What we found is that nurse practitioners are competent, specially trained clinicians who are accessible with a hyperfocus on holistic communication and holistic treatment plans for the whole patient. When you look at patient outcomes for nurse practitioners compared to their colleagues, these outcomes show that the care is equitable or comparable. And in some areas, outcomes for patients that work with nurse practitioners is better. I think it's really important that we fight against this notion that nurse practitioners are somehow a mid-level provider or a sub-performing provider, because it's not what the literature is saying. I don't think that's what patients are experiencing. I'd say the last thing that we really understand is that in order for this multidisciplinary collaboration model to work, it has to require that the team members share common goals and values for their patients. I think this is huge, in that they share mutual respect for one another and of course, and then that they have excellent communication. So when we put that together, we find that nurse practitioners can be successful in a variety of areas, can perform the same or achieve the same patient outcomes if not better when they're empowered to practice to the full extent of their license in mutually respective environments. Because there's no consensus in the PH community, I'll just take a moment to speak to my personal experience as being the first nurse practitioner in the pulmonary vascular disease program at the University of Washington and the first nurse practitioner in our pulmonary med specialties in general. In our clinic, we utilize a collaborative practice model with a focus on high acuity patients. Well, what does that mean? That means that I am empowered to practice to the full extent of my license. I carry my own personal set of patients. And because of my time and accessibility, I focus on supporting the sickest patients across our entire clinic. Patients with pulmonary vascular disease, whether that's CTEPH, whether they're living with PAH, they have what we know is progressive serious lung and heart disease. Because of the nature of this disease and its impacts on the patient's hemodynamics and their overall day-to-day life, most of our patients are out living in the world with severe heart and lung disease. They struggle with things like volume management, lifestyle modifications, limiting their salt, limiting their fluids, weighing themselves, taking these complex medications, titrating on medications with serious side effects, all of which really require intense available support from their providers. So what we have found in our clinic is that our patients are doing better when we have somebody who is competent and able to respond to those urgent needs. We really are finding that my role has allowed our whole team to provide more preventative care, to intervene earlier, helping avoid hospitalizations and really improving outcomes for our patients across the board. I think that when we are asking ourselves, how can we best utilize these different experts in medicine, in healthcare, the answer is that we need to create solutions that allows each person to bring their expertise and to meet the needs of our patients. In our clinic, this is the model where we have found success. So again, it's my ability to get to have the time to really meet the unique needs of patients who are living with pulmonary hypertension. I would probably argue that all of our patients, even the ones that aren't struggling with critical illness in the moment, would probably benefit from working with their nurse practitioner in their clinic, because probably all of our patients with pulmonary hypertension warrant very intensive care in their day-to-day. Another way we use this model is in addition to carrying my own patient cohort and covering the high needs of the patients across the clinic, I also have capacity to consult on the inpatient side. That means that when our patients are admitted to our hospital or to some of our smaller hospitals in our neighboring states, I'm able to engage or fill the role as a consultant. At the University of Washington, we really cover what we call the WWAMI region. That means we cover patients that are in Washington, Wyoming, Alaska, Idaho, and Montana, which you can imagine is quite a large range. We work a lot with small community hospitals, local providers. Considering how rare PAH is, there is a lot of need to support our colleagues in caring safely for our patients. So by having this care model where I have the ability to work with our high need patients, that also gives me the ability to work with local providers to support them in caring for patients with pulmonary arterial hypertension in a unique way we were not able to do as well before. I also consult for our patients when they're in the hospital, helping guide their pulmonary vascular disease care, as well as helping when they find themselves in an emergency room in their town or on their way to us. I don't come from a background of healthcare providers. My mom got diagnosed with metastatic cancer when I was about 18. My first exposure to healthcare providers was watching those that cared for her through the end of her life. I would see my mom have these difficult days, and the people that were there to comfort her and support her were nurses. I remember sitting in this infusion room with her and she was crying. It was a difficult space. You could see patients of all points of their disease. I think for her, she could see the trajectory of where she was heading. I was only 20 maybe at the time and didn't know how to comfort her. I saw this nurse swoop in and hold her and say, these simple yet profound things that completely calmed my mother, gave her peace. I just thought to myself, "Oh my God, I want to do that for people." The next day I enrolled in my nursing program and then was more exposed to the different types of nursing. I've always enjoyed academics. I've always enjoyed the challenge of education and learning, and I really felt that critical care did two things for me. Working with critically ill patients gave me the satisfaction of challenging me intellectually. At the same time, it allowed me to support families and patients through death and dying. I think one of the things in losing my mom at a young age is that it has made me so aware of the presence that a provider can have and the lasting impact that they can make in trying to help hold that grief and move you through that grief. One of the things that attracted me to the ICU was that I got to do both those things. I got to have these deep connected conversations with strangers on some of their most difficult days. Simultaneously, I was learning and growing and constantly challenged by the new thing that I was facing in front of me. I practiced as a critical care nurse for about 13 years before I became a nurse practitioner. I intersected with patients living with pulmonary hypertension once they had hit the ICU or critical illness. I always found these patients to be young, resilient and really remarkable people living out their lives struggling with a very serious illness. I think I was first drawn to pulmonary vascular disease, because I was drawn to the patients. I was drawn to that therapeutic relationship and caring for patients in the ICU. I think it was a natural then progression that when I became a nurse practitioner, that I was attracted to working in pulmonary vascular disease field because it is a complex disease. It challenges me to understand physiology which I'm interested in. Patients are critically ill and yet out living their lives in our community, meaning that I felt that the nurse practitioner role could really support patients to stay out of the hospital living their lives. I think it felt like a natural progression from the intensive care unit to a place where I wanted to grow my own practice, caring for critically ill patients that are living out in the community that have very complex physiology that challenge me both intellectually as well as emotionally caring for such a really remarkable group of people. I think just overall, what are the two things I really hope to communicate is I think that nurse practitioners are specially trained, accessible, and competent clinicians. When we operate in these collaborative care models with mutual respect and supported to practice at the full extent of our license, patients do better. I also think that patients living with pulmonary hypertension have unique needs that nurse practitioners can meet, because of that competence and accessibility. I think that programs across the country would see an improvement for their patients if they adopted this collaborative model and really supported and celebrated the role of nurse practitioners in the care of patients with pulmonary hypertension. My name is Lia Barros, and I'm aware that I'm rare.

Learn more about pulmonary hypertension trials at www.phaware.global/clinicaltrials. Follow us on social @phaware Engage for a cure: www.phaware.global/donate #phaware Share your story: info@phaware.com @uwepidemiology 

Listen and View more on the official phaware™ podcast site

[lucysweatslove]

Updates? Yeah, life updates.

The Tech concert was good. He’s a goofy dude and you can tell he just really has fun with it. Husband got smashed and had a grand ol’ time. I took a ton of videos for him.

Because of the concert yesterday, I was very clear at work that I could NOT stay late which ended up causing problems. Usually this is fine, but a) we had a late scheduled patient, b) my trainee is still working on speed, and c) literally at like 5:15 my entire workstation stopped connecting to work apps or anything on google chrome or whatever the edge thing is that replaced IE. I could access the EMR but no videos or email or even IT help. I was on my phone trying to connect and figure it out. Eventually I got it half working but I had to leave then. We had 4 notes left, one I was working on, one my trainee was working on, and two ones we hadn’t even found media for yet. My trainee said she would work on the notes herself and I could review in the morning…

I woke up early and clocked into work before I’m normally awake to finish up yesterday’s work, right? My trainee has done one extra note, staying late to do it, which was great of her, but that still meant I had to do one new note on a very long visit with a patient with a complex history, finish up the note I had started when my computer did the weird connection thing, AND THEN also review my trainee’s other two notes. It’s not a quick process because I have to fix anything missed and she’s still learning. And this doc is literally taking like an hour to do her visits.

Anyway I started work at 8 AM when I normally start at 10, and I finished getting ready for today’s clinic writing about 10:30 and then tried to find media… no media. I was stressed because this doc had a very busy AM hearing loss clinic (about twice as many patients as usual), and while she normally just does the AM clinic on those days, she also added in a busy PM clinic in person. It was just me + my trainee. Other staff who work with that doc were scheduled to only work a half day and deal with a full clinic themselves + help with another clinic, too.

Anyway, I got in touch with my supervisor who said the doc doing the hearing clinic was taking those calls during her commute into work and thus wasn’t using our services in the AM. Which was great because that meant I could work on the other doc’s clinic for my coworker who wasn’t scheduled all day.

My coworker was actually super grateful because she was a little stressed, worrying how she would be able to finish her clinic. We don’t usually have days like today with 3+ providers in with full clinic schedules.

During my PM clinic, it turned out a resident was working, and this resident is highly competent and does notes like they’re supposed to!! Which was amazing. Out of 8 patients, we only were responsible for 2 of them, so my trainee got to to both!

While trainee was working in those notes, I was able to help out with the other two clinics.

During all of this, I was SO NAUSEATED and dizzy and running to the bathroom frequently. If I move my eyes, I get sick. Imagine trying to type and listen and watch a video when you want to vomit every time you move your eyes. 0/10.

Overall I worked for ~10 hours, minus maybe 45 min or so total for breaks when I absolutely needed. It was worth it though because nobody else on my team needed to stay late or cut into study time. If I hadn’t needed to come in early to resolve issues stemming from tech failure yesterday, it would’ve been just a normal day at work.

Now I’m still feeling really sick. No fever or anything. Still not sure what’s causing the dizziness. I have tomorrow off which is nice, but I still have a ton to do so it won’t really be a restorative day. I have heard back from all MD schools now, and have gotten secondary invites from all of them except one which is still reviewing my primary app. UNR and WWAMI came in yesterday, and I was working a little on my UNR app since it’s due next Tuesday, and I had to email them to ask about my sister (current resident; unsure if that makes her a UNR student or not). They haven’t gotten back to me which is *frustrating* but oh well.

Tomorrow’s goals re: med school-

Get my official voter registration certificate thingy so I can upload it.

Finish the app to verify my MT residency status for all the programs that need it verified.

UNR application. It’s fewer essays like Mayo, but it’s also *not Mayo* and essays are max 300 words instead of 500. I think I have 6-7 essays? I can’t remember as I didn’t formally count them and I know some are optional. But 7 essays at 300 words- probably a few hours? Maybe 4?

If time, U of Utah application. They have a lot more in depth stuff- like I have to put in all my activities again but they ONLY want stuff within the last 5 years. They make it sound like a positive because “some students have to select their top 15 activities.” I’m like… or some students don’t even have 15 real quantified activities to begin with because they have one activity spanning a long period of years. Honestly this really worries me because I’m non-trad, even tho I have amazing ties to the state and school in general (would be the third generation to complete any medical Ed there- my gpa did a fellowship and dad did resident).

I doubt I’ll have time after that but if I do, probably U of Arizona applications. They have two campuses done individually, so Tucson first and maybe Phoenix if a lot of the app is the same. Otherwise the Phoenix campus has a much later true deadline and I’ll want to prioritize WSU and WWAMI.

OHSU and then U of Minnesota (both campuses) and then WWAMI and then WSU (since they got back to me later I have a little more unofficial time to complete those).

Yeah it’s gonna be a busy day tomorrow. I work Friday, so my weekend is gonna be packed too. I’m hoping- HOPING- that I can do UNR and U of Utah tomorrow and then for my final 14 apps (assuming U of Iowa offers me a secondary), if I can do them in 3 hours each, I can effectively finish 6-8 this weekend. That would put me through everything officially due before mid-November at the earliest. While they really want you to send in secondaries two weeks after they’re offered, with full time work and literally no time to prepare bc they were offered so quickly, I have to prioritize. So schools I have less ties to are going to be submitted later since I have less chance of getting in those places.

[dtchdr85]

Well, it’s been a minute

Well, it’s been a minute

These last few months have been exhausting and soul crushing. I have been working a lot and trying to stay caught up on homework for the summer semester. I have been working on my Spanish class and Geography class lately. Not to mention attempting to work on the MCAT right?! NO! I got to finally speak with the pre-med advisor for WWAMI. (Hi April!). She strongly advised me to hold off on taking…

[tinamsuggs]

Data Management and Visualization - Week 1

My name is Tina M. Suggs.  This blog is part 1 of 5 courses in the Data Analysis and Interpretation Specialization track with Coursera. All assignments must be submitted through a blog. So, I chose Tumblr for assignment evaluation and to promote my progress throughout this specialization track.

Assignment 1:

In assignment 1, we were provided with five data sets to select a subcategory along with two topics and variables for our topic of interest.  The five data sets may be used in this course and throughout the entire specialization track.

STEP 1:  Choose a data set that you would like to work with.  

I chose the GapMinder data set. GapMinder is a non-profit venture promoting sustainable global development and achievement of the United Nations Millennium Development Goals. It seeks to increase the use and understanding of statistics about social, economic, and environmental development at local, national and global levels.

GapMinder collects data from a handful of sources, including the Institute for Health Metrics and Evaluation, US Census Bureau’s International Database, United Nations Statistics Division, and the World Bank.

More information is available at  www.gapminder.org

STEP 2:  Identify a specific topic of interest.

My specific topic of interest to explore is the Relation between Breast Cancer and income.  I chose this topic because this is Breast Cancer Awareness Month.

STEP 3:  Prepare a codebook of your own.

The GapMinder dataset consists of various attributes such as Income per person, alcohol consumption, CO2 emissions, employment rate, life expectancy etc.

Step 3 My Personal Codebook:

I’m exploring incomeperperson, breastcancerper100th and lifeexpectancy as variables.

STEP 4:  Identify a second topic that you would like to explore in terms of its association with your original topic.  

The second topic that you would I like to explore in terms of its association with topic one is urban rate.

STEP 5:  Add questions/items/variables documenting this second topic to your personal codebook.

Is there any relation between income and breast cancer?

Is there any relation between life expectancy and breast cancer?

Is there any relation between urban rate and breast cancer?

My Codebook:

STEP 6:  Perform a literature review to see what research has been previously done on this topic.

Affluence and Breast Cancer

According to GapMinder, “Breast Cancer is the most common form of cancer among women. Unlike cervical cancer, breast cancer is more common in rich countries than in low- and middle-income countries and also tends to increase as a country gets richer.”

Breast Cancer in Rural America

According to their study, “Women living in rural areas are screened for breast cancer less often than women in urban areas. One study from the WWAMI Rural Health Research Center (RHRC) found that, although overall participation in breast cancer screenings have increased over time, there is a persistent disparity between urban and rural women. At the time of the study, 75.7% of urban respondents had received timely mammography, but only 70.8% of rural women had."

STEP 7:  Based on your literature review, develop a hypothesis about what you believe the association might be between these topics.  Be sure to integrate the specific variables you selected into the hypothesis.

The urban rate is highly related to breast cancer because rural women don’t have as much access to support services as someone in urban areas. 

There is a correlation between women with higher incomes and life expectancy because they can afford better preventive screening, breast cancer care and have a better chance of surviving.

References:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6477537/

https://www.ruralhealthweb.org/blogs/ruralhealthvoices/october-2018/breast-cancer-in-rural-america

https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1467-842X.2000.tb00137.x

https://www.gapminder.org/videos/breast-cancer-statistics/

[fat-llama-floof]

if someone doesn’t make like friggin fancy-ass spiky boots like chanel or smth for llamas im gonna frinning rampage and die and yell the furry song while naked

“if no one wants to get into a f**ky-wucky you need to but the llami-wwami in the bootie-wooty”

FOR REFRENCE

[heavyweightheart]

Hey, just wanted to say I love you and you've been literally a major reason I've entered true recovery from my ED(s). I also wanted to ask a question. Do you think being a medical practitioner is necessarily bad because of all the fatphobia in the field right now? I'm going to medical school in the fall (through the UW WWAMI program so we'll be at the same school kind of) and I am super scared about the institutional fatphobia, but still really want to and feel drawn to being a doctor. (1)

I guess I’m just really looking for reassurance from people I trust a lot that going and trying to make a difference from the inside is the right decision. It’s gonna be really hard being exposed to the fatphobia, but, then again, if not me who? If not now when? If you get what I mean (2)

--

Congrats!! I think that if you feel prepared physically and emotionally to go thru medical school, then entering the medical field with a HAES orientation is a huge gift to the world, and could be so worth it! But your health is as important as anyone else’s, and it’s not up to you individually to eradicate fatphobia in the medical field or in academia. Your best is good enough.

I would make sure you have lots of good support personally and professionally, and in fact (I’m a nerd so ymmv) I would reach out to some of the doctors who are forging this path in medicine already���we have a great one here at the UW Medical Center (Lisa Erlanger, MD), Dr. Emily Cooper at Seattle Performance Medicine (o-words cw if you google), and Dr. Jennifer Gaudiani in Colorado. The HAES directory will certainly have more.

Maybe we can meet up on campus if/when you’re here and complain about our respective programs :) I heard there’s a fat activism group at UW, and at least one doctoral candidate in the school of social work is in FA, so stay connected, even if it’s virtually! xx

[cchen98006]

Finally got around to editing. This was one of the most epic flights I’ve ever experienced! Yellowstone may be the most famous location in the area, but there is SO much beauty outside of the park, within 2 hours radius. So lucky UW put me here because I probably wouldn’t have known to come here on my own... 🌊🏔❄️🌲📸✈️#WWAMI #WWAMIadventures #UWSOM #HolyCity #CodyWY #Yellowstone #ArtemisFlies #Wyoming #ThatsWY #Drone #Drones #womenwhodrone #mavicpro #DJI #dronestagram #dronephotography https://www.instagram.com/p/B9Zdzkjg84f/?igshid=1f15imvt33fay

[scitechman]

Future Combat Medics to Train on Next-gen Manikin That Bleeds

Future Combat Medics to Train on Next-gen Manikin That Bleeds

Troy Reihsen was doing his best to save the injured soldier in front of him.

“You’re going to be OK, buddy, just stay with me,” Reihsen said as he tied a tourniquet on the hemorrhaging right leg, blown off below the knee.

After ensuring that the bleeding had stopped and other wounds had been addressed, Reihsen declared the soldier ready for transport.

The manikin’s softwarealso communicates…

[scottbcrowley2]

UI to request WWAMI, research funding from ed board - Wed, 09 Aug 2017 PST

The University of Idaho will request an additional $4 million in its permanent building fund for fiscal year 2019 at the Idaho State Board of Education’s monthly meeting Thursday so it can begin design and construction on an 80,000-square-foot companion building to the recently completed $50 million Integrated Research and Innovation Center. UI to request WWAMI, research funding from ed board - Wed, 09 Aug 2017 PST

[jighap]

STEP 1: Choose a data set that you would like to work with. 

I chose the GapMinder data set. GapMinder is a non-profit venture promoting sustainable global development and achievement of the United Nations Millennium Development Goals. It seeks to increase the use and understanding of statistics about social, economic, and environmental development at local, national and global levels.

GapMinder collects data from a handful of sources, including the Institute for Health Metrics and Evaluation, US Census Bureau’s International Database, United Nations Statistic Division, and the World Bank.

STEP 2. Identify a specific topic of interest

My specific topic of interest to explore is the Relation between Breast Cancer and income.

STEP 3. My Personal Codebook

I’m exploring incomeperperson, breastcancerper100th and lifeexpectancy as variables.

STEP 4. Identify a second topic that you would like to explore in terms of its association with your original topic.

The second topic that you would like to explore in terms of its association with topic one is urban rate.

STEP 5. Add questions/items/variables documenting this second topic to your personal codebook.

·          Is there any relation between income and breast cancer?

·          Is there any relation between life expectancy and breast cancer?

·          Is there any relation between urban rate and breast cancer?

My Codebook:

STEP 6. Perform a literature review to see what research has been previously done on this topic.

Affluence and Breast Cancer

According to GapMinder, “Breast Cancer is the most common form of cancer among women. Unlike cervical cancer, breast cancer is more common in rich countries than in low- and middle- income countries and also trends to increase as a country gets richer.

Breast Cancer in Rural countries

According to the study, “Women living in rural areas are screened for breast cancer less often than women in urban areas. One study from the WWAMI Rural Health Research Centre (RHRC) found that, although overall participation in breast cancer screenings have increased over time, there is a persistent disparity between urban and rural women. At the time of the study, 75.7% of urban respondents had received timely mammography, but only 70.8% of rural women had.

STEP 7. Based on your literature review, develop a hypothesis about what you believe the association might be between these topics. Be sure to integrate the specific variables you selected into the hypothesis.

·          The urban rate is highly related to breast cancer because rural women don’t have as much access to support services as someone in urban areas.

·          There is a correlation between women with higher incomes and life expectancy because they can afford better preventive screening, breast cancer and have a better chance of surviving.

[wizworldlettyfiles]

[yasbxxgie]

View this post on Instagram

A post shared by Kevin Coombe (@dcsoulrecordings)

DC band "The Young Senators" cut two singles prior to signing with Innovation Records. Their second effort was recorded at Swami studio in 1967 and showcased a dance called the "Funky Freeze".

[twanna792932]

https://t.co/vgPuVoxTMV WWAMI medical students must work in Montana or pay higher fees Starting next year, Montana medical students enter…

https://t.co/vgPuVoxTMV WWAMI medical students must work in Montana or pay higher fees Starting next year, Montana medical students enter…

— Rochester, NY 14603 (@Rochester_14603) June 30, 2017

from Twitter https://twitter.com/Rochester_14603 June 30, 2017 at 06:37AM via DC

[dzureiku1983]

WWAMI medical students must work in Montana or pay higher fees https://t.co/o00frzLOir Starting next year, Montana medical students enter…

WWAMI medical students must work in Montana or pay higher fees https://t.co/o00frzLOir Starting next year, Montana medical students enter…

— Utah, USA (@ybuasifogy) June 30, 2017

from Twitter https://twitter.com/ybuasifogy June 30, 2017 at 06:38AM via IFTTT

[mglintnek]

WWAMI medical students must work in Montana or pay higher fees https://t.co/o00frzLOir Starting next year, Montana medical students enter…

http://twitter.com/ybuasifogy/status/880737354406932480

WWAMI medical students must work in Montana or pay higher fees https://t.co/o00frzLOir Starting next year, Montana medical students enter…

— Utah, USA (@ybuasifogy) June 30, 2017

from Twitter https://twitter.com/ybuasifogy June 30, 2017 at 06:38AM DC