Ethylene Oxide (ETO) Sterilized Sampling Swabs


  • Ethylene Oxide "Gas" Sterilization.
  • Ethylene oxide is industrially produced by oxidation of ethylene in the presence of silver catalyst.
  • Chronic exposure to ethylene oxide is also mutagenic.
  • The International Agency for Research on Cancer classifies ethylene oxide into group 1, meaning it is a proven carcinogen.
  • CDC: ETO toxicity has been established in a variety of animals. 
  • CDC: Exposure to ETO can cause eye pain, sore throat, difficulty breathing and blurred vision
  • CDC: Exposure can also cause dizziness, nausea, headache, convulsions, blisters and vomiting and coughing.
  • CDC: ETO has been linked to spontaneous abortion, genetic damage, nerve damage, peripheral paralysis, muscle weakness, and impaired thinking and memory.

Ethylene Oxide Sterilized sampling swabs


Coventry Sterile Sampling Swabs

Coventry™ Sterile Sampling Swabs have been engineered to efficiently collect biological fluids for elution and analysis especially nasopharyngeal and oropharyngeal sampling. 

Sampling Swabs are ETO sterilized -- free from human DNA, enzymes that degrade DNA and RNA, and polymerase chain reaction inhibitors.

Swab heads are available with either flocked or foam material. Brush-like flocked microfiber swabs are more comfortable, soft, and absorbent with high surface area for rapid capillary absorption of fluid specimens.

Coventry Sterile Sampling Swabs provide more consistent and repeatable sample collection to drastically reduce resampling.

Factory Certificates available:

  • FDA Registered
  • ISO13485:2016 since 2018 (TÜV Rheinland)
  • EC Certificate Dir 93/42/EEC Annex V
  • Made for COVENTRY™ by Miraclean

STERILE FLOCKED SWABS

  • Head: Nylon Microfiber
  • Handle: Polystyrene or ABS
  • Microfiber provides high surface area for rapid capillary absorption of fluid specimens.
  • Flocking (brush-like nylon fibers) ideal for sample collection from irregular surfaces.
  • Head material structure is linear and open, which facilitates rapid absorption and thorough release of specimen into analyzing solution.

STERILE FOAM SWABS

  • Head: Polyurethane foam
  • Handle: Polystyrene or ABS
  • 100 ppi reticulated foam structure for maximum absorption
  • Foam cell structure is open, which facilitates rapid absorption and thorough release of specimen into analyzing solution.

https://www.chemtronics.com/coventry-flocked-sampling-swab

__

Ethylene Oxide "Gas" Sterilization

The use of ETO evolved when few alternatives existed for sterilizing heat- and moisture-sensitive medical devices; however, favorable properties (Table 6) account for its continued widespread use.872 Two ETO gas mixtures are available to replace ETO-chlorofluorocarbon (CFC) mixtures for large capacity, tank-supplied sterilizers. The ETO-carbon dioxide (CO2) mixture consists of 8.5% ETO and 91.5% CO2. This mixture is less expensive than ETO-hydrochlorofluorocarbons (HCFC), but a disadvantage is the need for pressure vessels rated for steam sterilization, because higher pressures (28-psi gauge) are required. The other mixture, which is a drop-in CFC replacement, is ETO mixed with HCFC. HCFCs are approximately 50-fold less damaging to the earth’s ozone layer than are CFCs. The EPA will begin regulation of HCFC in the year 2015 and will terminate production in the year 2030. Two companies provide ETO-HCFC mixtures as drop-in replacement for CFC-12; one mixture consists of 8.6% ETO and 91.4% HCFC, and the other mixture is composed of 10% ETO and 90% HCFC.872 An alternative to the pressurized mixed gas ETO systems is 100% ETO. The 100% ETO sterilizers using unit-dose cartridges eliminate the need for external tanks.

The main disadvantages associated with ETO are the lengthy cycle time, the cost, and its potential hazards to patients and staff; the main advantage is that it can sterilize heat- or moisture-sensitive medical equipment without deleterious effects on the material used in the medical devices (Table 6). Acute exposure to ETO may result in irritation (e.g., to skin, eyes, gastrointestinal or respiratory tracts) and central nervous system depression.859-862 Chronic inhalation has been linked to the formation of cataracts, cognitive impairment, neurologic dysfunction, and disabling polyneuropathies.860, 861, 863-866Occupational exposure in healthcare facilities has been linked to hematologic changes 867 and an increased risk of spontaneous abortions and various cancers318, 868-870. ETO should be considered a known human carcinogen.871

The basic ETO sterilization cycle consists of five stages (i.e., preconditioning and humidification, gas introduction, exposure, evacuation, and air washes) and takes approximately 2 1/2 hrs excluding aeration time. Mechanical aeration for 8 to 12 hours at 50 to 60°C allows desorption of the toxic ETO residual contained in exposed absorbent materials. Most modern ETO sterilizers combine sterilization and aeration in the same chamber as a continuous process. These ETO models minimize potential ETO exposure during door opening and load transfer to the aerator. Ambient room aeration also will achieve desorption of the toxic ETO but requires 7 days at 20°C. There are no federal regulations for ETO sterilizer emission; however, many states have promulgated emission-control regulations.814


ETO is absorbed by many materials. For this reason, following sterilization the item must undergo aeration to remove residual ETO. Guidelines have been promulgated regarding allowable ETO limits for devices that depend on how the device is used, how often, and how long in order to pose a minimal risk to patients in normal product use.814

ETO toxicity has been established in a variety of animals. Exposure to ETO can cause eye pain, sore throat, difficulty breathing and blurred vision. Exposure can also cause dizziness, nausea, headache, convulsions, blisters and vomiting and coughing.873 In a variety of in vitro and animal studies, ETO has been demonstrated to be carcinogenic. ETO has been linked to spontaneous abortion, genetic damage, nerve damage, peripheral paralysis, muscle weakness, and impaired thinking and memory.873 


Occupational exposure in healthcare facilities has been linked to an increased risk of spontaneous abortions and various cancers.318 Injuries (e.g., tissue burns) to patients have been associated with ETO residues in implants used in surgical procedures.874 Residual ETO in capillary flow dialysis membranes has been shown to be neurotoxic in vitro.875 OSHA has established a PEL of 1 ppm airborne ETO in the workplace, expressed as a TWA for an 8-hour work shift in a 40-hour work week. The “action level” for ETO is 0.5 ppm, expressed as an 8-hour TWA, and the short-term excursion limit is 5 ppm, expressed as a 15-minute TWA814. For details of the requirements in OSHA’s ETO standard for occupational exposures, see Title 29 of the Code of Federal Regulations (CFR) Part 1910.1047.873 Several personnel monitoring methods (e.g., charcoal tubes and passive sampling devices) are in use.814 OSHA has established a PEL of 5 ppm for ethylene chlorohydrin (a toxic by-product of ETO) in the workplace.876 Additional information regarding use of ETO in health care facilities is available from NIOSH.


Mode of Action

The microbicidal activity of ETO is considered to be the result of alkylation of protein, DNA, and RNA. Alkylation, or the replacement of a hydrogen atom with an alkyl group, within cells prevents normal cellular metabolism and replication.877

Microbicidal Activity

The excellent microbicidal activity of ETO has been demonstrated in several studies 469, 721, 722, 856, 878, 879 and summarized in published reports.877 ETO inactivates all microorganisms although bacterial spores (especially B. atrophaeus) are more resistant than other microorganisms. For this reason B. atrophaeus is the recommended biological indicator.

Like all sterilization processes, the effectiveness of ETO sterilization can be altered by lumen length, lumen diameter, inorganic salts, and organic materials.469, 721, 722, 855, 856, 879 For example, although ETO is not used commonly for reprocessing endoscopes,28 several studies have shown failure of ETO in inactivating contaminating spores in endoscope channels 855or lumen test units 469, 721, 879 and residual ETO levels averaging 66.2 ppm even after the standard degassing time.456 Failure of ETO also has been observed when dental handpieces were contaminated with Streptococcus mutans and exposed to ETO.880 It is recommended that dental handpieces be steam sterilized.

Uses

ETO is used in healthcare facilities to sterilize critical items (and sometimes semicritical items) that are moisture or heat sensitive and cannot be sterilized by steam sterilization.

https://www.cdc.gov/infectioncontrol/guidelines/disinfection/sterilization/ethylene-oxide.html

__


Essential Guide to Sterile Sampling Swabs

Note: This paper is intended as an overview on the topic of sampling swabs and not as an authoritative how-to guide. Consult CDC and other similar sources for specific guidelines. Per CDC guidelines, “All testing for SARS-CoV-2 should be conducted in consultation with a healthcare provider."

The COVID-19 pandemic of 2020, which is caused by the SARS-CoV-2 (commonly known as the novel coronavirus), has caused a huge spike in demand for sampling swabs. While there have been swab shortages to fill the urgent need of COVID-19 testing, care still needs to be taken to qualify and source the best swab for the type of sampling that is required.

Chemtronics offers a line of Coventry™ Sterile Sampling Swabs [https://www.chemtronics.com/coventry-flocked-sampling-swab] that are FDA approved and manufactured and sterilized to the highest standard.

The following is a guide that provides an overview of sampling used for COVID-19, flu and other similar testing. For more information, go to CDC guidelines at https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html.

Methods of Sampling

When performing initial diagnostic testing for SARS-CoV-2, the CDC recommends sampling from the upper respiratory system with one of the following methods:

  • Nasopharyngeal Sampling
  • Oropharyngeal Sampling
  • Nasal Mid-Turbinate Sampling
  • Anterior Nares Sampling

 

Nasopharyngeal Sampling

Nasopharyngeal sampling collects a nasal secretion sample from the back of the nose and throat. Per CDC recommendations, the swab should be made of a synthetic material with a flexible wire or plastic shaft.

Chemtronics® offers the Coventry™ Sterile Flocked Swab (part #66000ST, see fig 1) that has been engineered to efficiently collect biological fluids for elution and analysis.  Flocked nylon has fibers that provide greater surface area to collect and absorb secretion, and it is also more comfortable than many alternatives. 

Fig 1 – Coventry 66000ST Sterile Flocked Swab

The head material of Coventry 66000ST Sterile Flocked Swab is a nylon microfiber with a polystyrene (or ABS) handle. Microfiber provides high surface area for rapid capillary absorption of fluid specimens. Flocking (brush-like nylon fibers) ideal for sample collection from irregular surfaces. Head material structure is linear and open, which facilitates rapid absorption and thorough release of specimen into analyzing solution.

 

Nasopharyngeal sampling procedure:
(per CDC guidelines)

  1. Tilt the head back at a 70 degree angle.
  2. Insert the swab through the nostril, and keep it parallel to the palate, not upwards. (see fig 2)
  3. Make sure you stop when you feel resistance or the distance from the ear to the nostril is the same, which indicates the swab head is in contact with the nasopharynx.
  4. Gently roll the swab handle in your fingertips, which rotates the swab head.
  5. For several seconds, keep the swab in place to absorb the maximum amount of nasal secretions.
  6. Remove the swab from the nose slowly and carefully while rolling in your figertips. (see fig 3)
  7. Insert the swab head into a sterile transport media tube, snap off the swab handle and the break-point, seal cap, and identify sample. (see fig 4)

    

Fig 2, 3, 4

 

Oropharyngeal Sampling

Oropharyngeal sampling collects a secretion sample from the back of the throat. Per CDC recommendations, the swab should be made of a synthetic material with a flexible wire or plastic shaft.

Chemtronics® offers the Coventry™ Sterile Foam Swab (part #66120ST, see fig 5) that has been engineered to efficiently collect biological fluids for elution and analysis.

Fig 5 – Coventry 66120ST Sterile Foam Swab

The head material of Coventry 66120ST Sterile Foam Swab is polyurethane foam with a polystyrene (or ABS) handle. 100 ppi reticulated foam structure provides maximum absorption. The foam cell structure is open, which facilitates rapid absorption and thorough release of specimen into analyzing solution.

 

Oropharyngeal sampling procedure:
(per CDC guidelines)

  1. Tilt the head back at a 70 degree angle.
  2. Open mouth and create an open pathway by depressing the tongue.
  3. Carefully insert the swab head into the posterior pharynx and tonsillar areas.  (see fig 6)
  4. Rub the swab head over tonsillar pillars and posterior oropharynx, while avoiding contact with the tongue, gums, and teeth.
  5. Insert the swab head into a sterile transport media tube, snap off the swab handle and the break-point, seal cap, and identify sample. (see fig 4 above)

Fig 6

 

Nasal Mid-Turbinate Sampling

Nasal mid-turbinate sampling collects a nasal secretion sample from inside the nose. Per CDC recommendations, the swab head should be made of a flocked material and tapered shape, with a flexible wire or plastic shaft.

Chemtronics® offers the Coventry™ Sterile Flocked Swab (part #66010ST, see fig 7) that has been engineered to efficiently collect biological fluids for elution and analysis.  Flocked nylon has fibers that provide greater surface area to collect and absorb secretion, and it is also more comfortable than many alternatives. 

Fig 7 – Coventry 66010ST Sterile Flocked Swab


The head material of Coventry 66010ST Sterile Flocked Swab is a nylon microfiber with a polystyrene (or ABS) handle. Microfiber provides high surface area for rapid capillary absorption of fluid specimens. Flocking (brush-like nylon fibers) ideal for sample collection from irregular surfaces. Head material structure is linear and open, which facilitates rapid absorption and thorough release of specimen into analyzing solution.

 

Nasal mid-turbinate sampling procedure:
(per CDC guidelines)

  1. Tilt the head back at a 70 degree angle.
  2. While rotating the swab by rolling the handle in fingertips, gently insert swab less than one inch (about 2 cm) into nostril. Stop when you feel resistance at turbinates. (see fig 8)
  3. Then rotate the swab several times against nasal wall. (see fig 8)
  4. Repeat the process in the other nostril with the same swab.
  5. Insert the swab head into a sterile transport media tube, snap off the swab handle and the break-point, seal cap, and identify sample. (see fig 4 above)

Fig 8

 

Anterior Nares Sampling

Anterior nares sampling collects a nasal secretion sample from just inside the nose. Per CDC recommendations, the swab head should be made of a flocked material with a flexible wire or plastic shaft.

Chemtronics® offers the Coventry™ Sterile Flocked Swab (part #66010ST, see fig 9) that has been engineered to efficiently collect biological fluids for elution and analysis.  Flocked nylon has fibers that provide greater surface area to collect and absorb secretion, and it is also more comfortable than many alternatives. 

Fig 9 – Coventry 66010ST Sterile Flocked Swab

The head material of Coventry 66010ST Sterile Flocked Swab is a nylon microfiber with a polystyrene (or ABS) handle. Microfiber provides high surface area for rapid capillary absorption of fluid specimens. Flocking (brush-like nylon fibers) ideal for sample collection from irregular surfaces. Head material structure is linear and open, which facilitates rapid absorption and thorough release of specimen into analyzing solution.

 

Anterior nares sampling procedure:
(per CDC guidelines)

  1. Tilt the head back at a 70 degree angle.
  2. Insert the swab at least ½” (1 cm) inside the nostril (see fig 10) and firmly sample the sides of the nasal interior by rotating the swab.
  3. Leave in place 10 to 15 seconds.
  4. Repeat the process in the other nostril with the same swab.
  5. Insert the swab head into a sterile transport media tube, snap off the swab handle and the break-point, seal cap, and identify sample. (see fig 4 above)

Fig 10

 

Types of Sampling Swabs

For the various testing methods detailed above, the CDC guidelines recommend the head material be made of synthetic material, and specifies flocked surface for all but oropharyngeal sampling. Per the same guidelines, handle material should be synthetic material or metal, because use calcium alginate swabs or swabs with wooden shafts may contain substances that inactivate some viruses and reduce accuracy.

Coventry Sterile Sampling Swabs are available that meet CDC guidelines.

Foam

The head material of Coventry 66120ST Sterile Foam Swab is polyurethane foam with a polystyrene (or ABS) handle. 100 ppi reticulated foam structure provides maximum absorption. The foam cell structure is open, which facilitates rapid absorption and thorough release of specimen into analyzing solution. (see fig 11)

Fig 11 – detail of foam swab head

Flocked

Chemtronics® offers the Coventry™ 66010ST and 66120ST Sterile Flocked Swabs efficiently collect biological fluids for elution and analysis.  Flocked nylon has fibers that provide greater surface area to collect and absorb secretion, and it is also more comfortable than many alternatives.  The head material of Coventry 66010ST Sterile Flocked Swab is a nylon microfiber with a polystyrene (or ABS) handle. Microfiber provides high surface area for rapid capillary absorption of fluid specimens. Flocking (brush-like nylon fibers) ideal for sample collection from irregular surfaces. Head material structure is linear and open, which facilitates rapid absorption and thorough release of specimen into analyzing solution. (see fig 12)

Fig 12 – detail of flocked swab head

Handles

Coventry Sterile Sampling Swabs have handles made of polystyrene (or ABS), so meet CDC guideline for synthetic material to be used. Handles are scored for easy breaking for insertion into the transport vial. (see fig 13)

Fig 13 – detail of scored swab handle

 

Sterilization Methods

Coventry Sterile Sampling Swabs are sterilized using the ethylene oxide (EtO or EO) process, which ensures the swabs are free from human DNA, enzymes that degrade DNA and RNA, and polymerase chain reaction inhibitors.

The following are the three most common methods of swab sterilization:

  • Ethylene oxide (EtO or EO) - EtO is a sterilization method that utilizes medium temperature between 99-145°F (37–63°C), which creates a chemical reaction of proteins and DNA within the bacteria or viruses. The final step of the process is heated air circulation at temperatures typically between 122-140°F (50-60°C) to remove the EO gas from products and packaging.
  • Autoclaves – Autoclave sterilization uses steam and pressure to increase the temperature between 250-270°F (121-132°C) to kill bacterial and viruses.
  • Gamma irradiation – Gamma irradiation sterilization uses a radioactive material that emits high energy gamma rays, which breaks down the DNA within the bacteria or viruses.

 

Handling Procedures

Coventry Sampling Swabs come in individually sterile packaged. Each package is lot coded for quality control traceability. The back of each package contains brief instructions. (see fig 14)

Fig 14 – Coventry Sterile Sampling Swab packaging

 

To avoid contamination, follow these handling guidelines:

  • Peel apart the handle-side of the package.
  • The swab should only be gripped by the part of the handle above the scored break-point.

Insert the swab into the transport medium and break the handle at the breakpoint after sampling

Fig 15, 16, 17

 

Chemtronics offers a line of Coventry™ Sterile Sampling Swabs [https://www.chemtronics.com/coventry-flocked-sampling-swab] that are FDA approved and manufactured and sterilized to the highest standard that can be used for COVID-19, flu and other testing.

For more information, go to www.coventrycleanroom.com or contact Mark Quigley, Chemtronics Life Sciences Manager, at mquigley@itwcce.com or 310-741-0056.

https://www.chemtronics.com/essential-guide-to-sterile-sampling-swabs

Sources:

Sampling procedures and guidelines - https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html

Figures 2-4, 6, 8 - https://www.cdc.gov/flu/pdf/professionals/flu-specimen-collection-poster.pdf

Sterilization methods - https://www.cdc.gov/infectioncontrol/pdf/guidelines/disinfection-guidelines-H.pdf

___

Ethylene oxide

Effects on humans and animals[edit]

Ethylene oxide is an alkylating agent; it has irritating, sensitizing and narcotic effects.[128] Chronic exposure to ethylene oxide is also mutagenic. The International Agency for Research on Cancer classifies ethylene oxide into group 1, meaning it is a proven carcinogen.[129][130] Ethylene oxide is classified as a class 2 carcinogen by the German MAK commission and as a class A2 carcinogen by the ACGIH. A 2003 study of 7,576 women exposed while at work in commercial sterilization facilities in the US suggests ethylene oxide is associated with breast cancer incidence.[131] A 2004 follow up study analyzing 18,235 men and women workers exposed to ethylene oxide from 1987 to 1998 concluded "There was little evidence of any excess cancer mortality for the cohort as a whole, with the exception of bone cancer based on small numbers. Positive exposure-response trends for lymphoid tumors were found for males only. Reasons for the sex specificity of this effect are not known. There was also some evidence of a positive exposure-response for breast cancer mortality."[132] An increased incidence of brain tumors and mononuclear cell leukemia was found in rats that had inhaled ethylene oxide at concentrations of 10, 33 or 100 mL/m3 (0.0100, 0.0329 or 0.0997 imp fl oz/cu ft) over a period of two years.[133] An increased incidence of peritoneal mesotheliomas was also observed in the animals exposed to concentrations of 33 and 100 mL/m3 (0.0329 and 0.0997 imp fl oz/cu ft). Results of human epidemiological studies on workers exposed to ethylene oxide differ. There is evidence from both human and animal studies that inhalation exposure to ethylene oxide can result in a wide range of carcinogenic effects.

Ethylene oxide is toxic by inhalation, with a US OSHA permissible exposure limit calculated as a TWA (time weighted average) over 8 hours of 1 ppm, and a short term exposure limit (excursion limit) calculated as a TWA over 15 minutes of 5 ppm.[134] At concentrations in the air about 200 parts per million, ethylene oxide irritates mucous membranes of the nose and throat; higher contents cause damage to the trachea and bronchi, progressing into the partial collapse of the lungs. High concentrations can cause pulmonary edema and damage the cardiovascular system; the damaging effect of ethylene oxide may occur only after 72 hours after exposure.[24] 

The maximum content of ethylene oxide in the air according to the US standards (ACGIH) is 1.8 mg/m3 (0.00079 gr/cu ft).[135] NIOSH has determined that the Immediately Dangerous to Life and Health level (IDLH) is 800 ppm.[136]

Because the odor threshold for ethylene oxide varies between 250 and 700 ppm, the gas is already at toxic concentrations when it can be smelled. Even then, the odor of ethylene oxide is sweet, aromatic, and can easily be mistaken for the pleasant aroma of diethyl ether, a common laboratory solvent of very low toxicity. In view of these insidious warning properties, continuous electrochemical monitors are standard practice, and it is forbidden to use ethylene oxide to fumigate building interiors in the EU and some other jurisdictions.[137]

Ethylene oxide causes acute poisoning, accompanied by a variety of symptoms.[128] Central nervous system effects are frequently associated with human exposure to ethylene oxide in occupational settings. Headache, nausea, and vomiting have been reported.[clarification needed] Peripheral neuropathy, impaired hand-eye coordination and memory loss have been reported in more recent case studies of chronically-exposed workers at estimated average exposure levels as low as 3 ppm (with possible short-term peaks as high as 700 ppm).[133] The metabolism of ethylene oxide is not completely known. Data from animal studies indicate two possible pathways for the metabolism of ethylene oxide: hydrolysis to ethylene glycol and glutathione conjugation to form mercapturic acid and meththio-metabolites.

Ethylene oxide easily penetrates through ordinary clothing and footwear, causing skin irritation and dermatitis with the formation of blisters, fever and leukocytosis.[128]

Toxicity data for ethylene oxide are as follows:[134]

  • Eye exposure: 18 mg (0.28 gr)/6 hours (rabbit)
  • Oral: 72 mg/kg (0.00115 oz/lb) (rat, LD50), 1,186 mg/kg (0.01898 oz/lb) (rat, TDLo), 5,112 mg/kg (0.08179 oz/lb) (rat, TD)
  • Inhalation: 12,500 ppm (human, TCLo), 960 ppm/4 hours (dog, LC50) 33–50 ppm (rat or mouse, TC), 800 ppm/4 hours (rat or mouse, LC50)
  • Subcutaneous injection: 100 mg/kg (0.0016 oz/lb) (cat, LDLo), 292 mg/kg (0.00467 oz/lb) (mouse, TDLo) 900–2,600 mg/kg (0.014–0.042 oz/lb) (mouse, TD), 187 mg/kg (0.00299 oz/lb) (rat, LD50).
  • Intraperitoneal injection: 750 mg/kg (0.0120 oz/lb) (mouse, TDLo), 175 mg/kg (0.00280 oz/lb) (mouse, LD50)
  • Intravenous injection: 175 mg/kg (0.00280 oz/lb) (rabbit, LD50), 290 mg/kg (0.0046 oz/lb) (mouse, LD50)
  • The US Environmental Protection Agency (USEPA) estimated in 2016[138] that for low doses, the inhalation of ethylene oxide for a lifetime could increase an individual's lifetime cancer risk by as much as 3.0 × 10−3 per μg/m3 (without considering that early-life exposures are likely more potent). The USEPA estimated the slope of the dose-response declines at higher doses, and extra cancer risk estimates for several occupational exposure scenarios are calculated.

https://en.wikipedia.org/wiki/Ethylene_oxide#Physiological_effects

___


___

Ei kommentteja:

Lähetä kommentti