Stanford Professor Ron Davis Discusses ME/CFS and Toxic Mold Issues

 

April 12, 2019

By Lisa Petrison, Ph.D.

Research scientist Ronald W. Davis was interviewed about the possible role of various toxins (including mold toxins) in ME/CFS in an interview with Open Medicine Foundation advocate Ben Howell.

Ron Davis is a Professor of Biochemistry and Genetics at Stanford University.

The interview was presented as a YouTube video (linked above).

Following is a transcript of the interview.

 

Ben Howell: 

I should probably preface this for everyone – this is the most ad hoc, random Skype that I think that we both have ever had, isn’t it? And you’ve been incredibly gracious to let me have some time with you to talk about various things. So thank you for doing that.

It’s been a long time since we’ve spoken like this, in terms of giving people in the community an update.

One of the biggest pieces of news that I know people are kind of stoked about is the new CRC, the Collaborative Research Center with Jonas Bergquist of Uppsala University in Sweden.

 

Ron Davis: 

He has a very nice facility with a lot of high-end equipment. One of the particular values of using him is that he does a lot of spinal tap on patients, and he’s very good at it. That’s a concern with some of the patients in how you do a spinal tap, because sometimes they have a lot of pain with that. He says he does it in a good way that doesn’t have much pain. In fact, he said that patients would rather have a spinal tap than a standard blood draw, in terms of the level of pain. So that puts it into perspective.

And he does have access to ME/CFS patients. He’s done a number of experiments funded by the Open Medicine Foundation looking for antibodies.

I think it will be a good collaboration, especially when we would like to do something with the spinal fluid. Right now that’s sort of his area. We can certainly expand that.

And it’s useful to have a validation sometimes. When you find something that you think is important, you want to make sure that it’s reproducible in a different laboratory. So that’s another place that we will use him, because the facilities are pretty much like what we have.

We’ve been thinking about doing some trials with kynurenine injected into the spinal fluid. They’re doing similar experiments like that in a clinical trial for a different disease, which I don’t think I should talk about because it may be confidential. But things of that type, we would like him to work on.

And we may have him validate what we find in the metabolic trap and see if he finds the same thing with his patients. I always worry about different artifacts or equipment malfunctions, or all sorts of problems. You don’t want to get led into the wrong direction because of an instrumentation problems.

 

Ben Howell:

I remember you mentioning that before, in issues with mass spectrometry.

 

Ron Davis:

The amount of tryptophan and kynurenine in the cells is not very high. And the other major problem is that there aren’t very many cells that have the kynurenine pathway on. Probably about 1%. So that all reduces the signal.

I don’t know if he has the state-of-the-art mass spectrometers there, that have a high sensitivity, or not. But that would be what we would explore.

And also tell him what we have concluded about how to do the experiment and see if he concurs. Or he may decide to try it in a different way.

It’s all focused on trying to understand what’s really happening in this disease, and also how we might modulate it in some way or other.

What you’d like to have is the primary cause, and of course it’s always very difficult to make sure you’re actually on the primary cause and not on a sidetrack of some effect of the disease.

 

Ben Howell: 

I’m wondering about the metabolic trap itself, whether there was any news.

 

Ron Davis: 

We’ve been looking at the hair analysis, what is the standard error in our measurements. It’s pretty high. That’s making us a little bit concerned.  I think we need to have a more accurate determination.

The problems are the sensitivity of the mass spectrometer, the number of cells that have the pathway.

And then another problem that we realized is that we have to do an incubation in media. We use Eagle’s media, that’s classic. We didn’t realize at the time that equals media has 25 mg/ml of tryptophan. That dilutes our label. Plasma only has 5 mg/ml.

Eagle’s media was developed back in the 1950’s. They probably didn’t even know how much tryptophan was in the plasma.

But it worries us that we’re putting in pretty high tryptophan. So we have found some Eagle’s media without tryptophan. We’re now using that so that we can control the amount of tryptophan that the cells are incubated in. And we can increase the percent of the label, and that should give us an increase in signal.

Mike Snyder has let us use his very high-end mass spectrometer. He has actually three of them. And the post-doc who is running it is excited about this project. So he will pitch in helping us now. And he’s very experienced in it. So now we have two very experienced mass spectrometer people.

So we carried out that experiment all the way through with the changed media. We enriched for the dendritic cells by pulling out the T cells and B cells, and not including them. We still use the same number of cells, so that enriches for the antigen-presenting cells that are in the blood sample. And then that went into the higher sensitivity mass spectrometer.

All combined, that increases the signal about 100 fold, I think. That’s going to be a lot more accurate.

We have run one patient so far, under these conditions, and we get the same kind of increase in tryptophan reduction and kynurenine over a healthy control.

We have samples already collected from patients – I think enough that we can run, I think on Friday there were four samples ready to go into the mass spectrometer. Julie  has set aside cells frozen, and we can pull them out and use them. Hopefully that will go quickly. We’re hoping to get quite a few patient and healthy control samples in the next couple of weeks. And that would be a much more rigorous test of the hypothesis.

One of the considerations and complexities of this is that this trap is presumably a cellular-based process. So it could happen in one cell but not in another. And once it’s trapped, that cell is trapped. It’s also possible that the stem cells that are producing the immune cells could be trapped. And then all cells generated from that stem cell would continue to be trapped. These are complexities of the whole thing that we don’t totally understand. And so those need some explorations of that.

We would like to try to start some cell culture experiments. And that may be done by making stem cells and then generating the right types of cells from those stem cells. But that requires an expert in that field. We have to find one. There is a collaboration on this project where we will recruit somebody to the center to do that.

 

Ben Howell:

So much of this is cutting-edge research, and it requires almost new tests to be made, or tests that haven’t been run before.

 

Ron Davis: 

That’s correct. It seems like everything that we do has never been done before. So it’s always figuring it out.

If with a cell culture we can actually effectively create the disease, and get cells that aren’t trapped and then get them trapped, that would allow us to maybe set up a modeling system that would allow us to see how we could get them out of the trap. Because all the ideas that we have currently in the modeling are from measurements that were made years ago, and it’s always a possibility that something isn’t quite correct. It’s always important to check everything.

 

Ben Howell:

One thing that gets mentioned on the forums is the impedence device, that healthy cells – or as healthy as we can get – show an impedence signal to ME cells with ME patients’ serum. I’m wondering if there’s any progress on that. Because it’s such a dramatic thing, isn’t it, to see healthy patients’ cells seem to  have a very severe response to ME patients’ blood. It’s a headline, really.

 

Ron Davis:

We’ve written up the current status of it, because we’ve had a very good statistic. The probability that the difference could occur by chance was one chance in a billion. So that was sufficient to try to do a publication.

That has been reviewed by an engineer about the circuitry design. And it’s reviewed by a medical person who does diagnostic testing. So they made those suggestions, we made those corrections, the paper is going to Proceedings of National Academy of Science. We think it’s passed the review and is now at the editor. We think it’s good to go and it will be out soon.

We have done quite a few experiments trying to find out what it is. We’ve done some filtrations and it’s large. Now it appears that it’s quite large. It’s possible that it’s some kind of particle.

Of course, this could be mixed with some small molecules contributing and so forth. What we’re looking for is the thing that causes the biggest effect. It could be a particle. And so that’s where that is at the moment, trying to figure out what that particle might be.

We might try to purify that particle better and then break it apart and then either do a mass spec analysis of it or some other kind of analysis to see what is in the particle. That might give us a good clue.

But the biggest interest is to try to see if we can find some drugs that might abolish that signal.

That’s not necessarily a cure or even a treatment, but it’s possible. It would be worthwhile to find what kinds of compounds can reduce the signal.

But to do that, we really need to change the circuitry so that we can screen.

The amount of blood that we require for this is about one drop. So a blood draw can do many, many assays that would need independent circuits before that. There isn’t a commercial device that will do that. So we have to design it and build it. So that’s sort of where that’s at.

The research associate that was working with me, Rahim, has accepted a job at University of California at Irvine in electrical engineering. So that will allow him to bring in new students to help him work on the project. So it represents a bit of an expansion of the efforts.

A lot of stuff will still be run here at Stanford because we collect the patients’ blood and stuff. So the device development and other parts of that will happen in Irvine. It’s not that far away.

But the biological assays will probably continue to be run at Stanford, because if he does the biological stuff too, then he has to have a set up for collecting the blood and a mobile phlebotomist and someone to take charge of the patients. It would represent a duplication of effort, since we do that at Stanford anyway.

 

Ben Howell: 

It’s actually a very complex thing, to find this molecule or molecules. I kind of think of it like a fishing net and trying to scoop out things, but it’s really not like that, it’s a bit more complicated.

 

Ron Davis: 

Yes. The blood flow device – we’ve been doing a lot of modeling of a device to try to help in its design and made a new fabrication design. This is the red blood cell.

What we’re hoping for is something that gives us a bigger distinction. If this is going to be a diagnostic test, then it has to separate out all of the patients from healthy controls.

We’re setting that up so that when we start running other diseases, which are getting samples for that now, we want to look at the different technologies and how they differentiate between chronic fatigue syndrome and the other diseases.

The problem that we have is that chronic fatigue syndrome is initiated by a stressor. And  having another disease is a stressor. So it raises a problem in the sense that if you have MS, which is a pretty bad disease, is it possible that you also have chronic fatigue syndrome?

That’s pretty much dismissed by the physicians, because they even dismiss chronic fatigue syndrome from a healthy person. So when I’ve talked with them, they say it’s very unlikely to have two different diseases at the same time.

But they’re kind of similar in many ways. Certainly the MS patients have fatigue. And they say, that’s the fatigue caused by the MS.

So trying to do this experiment and see how other patients behave is a little complicated.  It’s not to complicated if the MS patients don’t show a signal, but it is complicated if they do.

 

Ben Howell:

Obviously red blood cell deformability isn’t just found in ME/CFS so far, it’s been found in lots of diseases.

 

Ron Davis: 

Exactly.

 

Ben Howell: 

Are they working yet with any drug targets, or is it yet a little too preliminary?

 

Ron Davis:

We haven’t set that up. We want to change the device so that we get a bigger effect on the deformability.

The new device is smaller. The channels are smaller. They process the red cells to be stretched out a lot more.

And we need to improve the imaging analysis. The problem is that as the cells move through this channel, they’re going to move pretty fast. If it sort of smears out because the picture isn’t taken fast enough, it makes our accuracy low.

So we really have to greatly improve on the imaging.

And then we have to make sure that that imaging analysis is automated. In the past, it wasn’t automated. It took hours of effort on each sample to get the numbers.

We also wanted to decrease the variance. One way to do this is to have the cell go through multiple constrictions and measure it multiple times, and then take the average. That may tighten up the distribution and therefore the accuracy.

 

Ben Howell: 

That’s not an established medical tool, is it?

 

Ron Davis: 

No.

 

Ben Howell: 

Another thing is the new board members – Daniel Peterson and Jennifer Frankovich and Michael Snyder.

 

Ron Davis:

Michael Snyder does big data analysis in looking at other diseases. He does a fair amount with similar kinds of diseases. He is also interested in chronic fatigue syndrome. He’s been thinking about it and coming to our working group meetings. He shows a lot of interest.

And we’re using a lot of his facilities. He’s in the same building – that’s another advantage. We’re on the first floor and he’s on the second floor. And we agreed when we moved in that we would share facilities so that we didn’t have a lot of duplication.

Dan Peterson has a lot of experience with the disease. He’s in the Incline Village area. That’s not too far. It’s a drive, so you don’t have to fly if you don’t want to. We have him because he has a lot of experience with the disease.

We’ve talked about a lot of projects that we might do in collaboration. A lot of that is with his samples. And he’s been trying a lot of things as well. So there’s a lot of opportunity there. And also given his vast experience in making suggestions in terms of what to try.

We had David Bell and we can still connect to David Bell by phone, but he’s really too frail to travel any more. So he really can’t come to our meetings. We keep him posted but we don’t really give him any work to do.

and so Dan Peterson is sort of a replacement for David Bell. David Bell is not off. It’s just that he really cannot help us as much.

 

Ben Howell: 

That’s unfortunate because David Bell really is a hero to a lot of people.

 

Ron Davis: 

And very knowledgeable and has a lot of experience.

Jennifer is at Stanford. We picked her because she knows a lot about chronic fatigue syndrome. But she also works on PANS. That has a lot of similarities. She’s tried lots of things.

It’s also my feeling that we need to learn from other closely related diseases. That may give us an idea of other types of experimentation to do or other possible treatments. In the case of PANS, they discovered it a little bit earlier. So she’s tried a number of treatments that have been successful when a patient hasn’t been sick for very long. She runs a PANS clinic. We plan to evaluate some of those patients with similar techniques that we’ve used on ME/CFS, to see what the similarities and differences are.

We do plan to do some collecting data on patients with fibromyalgia and chronic Lyme. But we have to raise money from those communities. We do not want to use money donated from chronic fatigue syndrome patients and caregivers and so forth to do research on a different disease. So the financial stuff will get compartmentalized.

We do have some donations from chronic Lyme. We’re setting up a collaboration with Bill Robinson, who is a rheumatologist. That’s another person who’s an M.D. He gets samples from the East Coast. There are organisms on the West Coast, but they’re slightly different, and so we will be using samples flown in from the East Coast for chronic Lyme and see how that compares to the ME/CFS data.

 

Ben Howell: 

The new CRC with Jonas Bergquist, how is that funded?

 

Ron Davis: 

I’ve gotten some patient donations from Sweden that will go to him. We’ll try to get more that will then go to him. Linda [Tannenbaum] is really more in charge of what we have and where we should put it, and with the advisory board talking about it.

Also there’s Mike Snyder. Although we have shared facilities, we probably should do something together. So one of the projects we’ve been discussing is trying to discover a wearable device, like a watch, that collects data from the patient. We’ve both had quite a bit of experience in that field from different points of view.

The goal is really to have a measurement so that we know when patients have gone to their limit and before they crash, and try to make it so they don’t crash.

 

Ben Howell: 

Is that something that would measure lactate?

 

Ron Davis:

So we could with biochemical – that’s the kind of things that we have done. It also could be a very sensitive device measuring heart rate variability. There probably is a signal in that, as well, that might tell you that there’s a level where there’s starting to be a physiological change. Mike has had some success with that with other diseases, in predicting before damage has been done.

 

Ben Howell: 

Is that in terms of heart rate variability?

 

Ron Davis: 

Heart rate, and you can do a number of things with temperature. You can get a change in temperature.

It’s very subtle. You have to have a high accuracy for this. Most of the devices are not adequate. The Fitbit, the Apple Watch – those are not adequate. The accuracies are not high enough. So you need a much more complex device that measures with high accuracy.

We’re going to look into the lactate possibility. That’s another possible way to do this. That would probably be done with sweat. That’s the simplest thing to do.

There are ways that you can do continuous blood monitoring, putting a tiny, tiny narrow needle into the skin. But sweat is also very sensitive. It hasn’t been looked at in the patients yet.

We can induce sweat electrically, so the patient does not have to be physically active to cause the sweating. This could be done even from someone who’s in bed. It’s not painful or anything of that type. We’ve worked out the methods for doing that.

 

Ben Howell: 

Because many ME patients don’t seem to sweat.

 

Ron Davis: 

Right, or exercise well either. The other correlation appears that if you’re in very, very good shape, you sweat more. So not sweating is actually a sign that you’re not in good physical shape. I don’t know how accurate that is, but we’ve seen that in trying to do the sweating. People sweat a different amount, which made us try to figure out how to electrically stimulate the sweating so that it didn’t require activity.

 

Ben Howell: 

I read recently that some healthy, fit people can sweat up to two liters a day, which seems an obscene amount.

 

Ron Davis: 

An obscene amount, yes. We have a device that is being tested out now, to measure the amount of sweat. The amount of sweat could very well be an indicator of physical fitness.

 

Ben Howell: 

For myself, being bedbound, I don’t think I’ve sweated properly in about five years.

 

Ron Davis: 

That’s very likely, yes.

 

Ben Howell:

What is the focus over the next few months? We’ve got Millions Missing and the London conference.

 

Ron Davis: 

There’s the London conference and there’s a conference at the end of this week at NIH. I don’t know how broadly that’s attended by international people, but they’re certainly welcome. It’s a two-day conference, so it’s a little bit small.

 

Ben Howell: 

Are they basically gathering input for their own studies?

 

Ron Davis: 

Supposedly they’re going to do a little bit of their own study. But I think it’s going to be pretty small. I thought they were going to do more, and that’s why I started out being excited about what they were doing. But I think it’s a fairly small amount.

 

Ben Howell: 

And obviously you’ll be at the Invest in ME conference.

 

Ron Davis: 

Yes. I plan to, yes. Hopefully we’ll have more data on the metabolic trap.

There is one more area that I could just briefly mention. It’s kind of a new area, and that’s more from looking at it from sort of an environmental engineering perspective.

We now have a professor who’s retired at Stanford in environmental engineering. He would like to come and, I think, join us, just to be part of an activity.

Because we’re seeing things like mercury toxicity in the patients, about a third.

We’re also seeing uranium in the patients, and mostly from California. We don’t know where that’s coming from or the consequence of that.

That person will help us maybe with some of the mold experiments, something we’ve been wanting to do for some time.

There’s just a lot of complexity in terms of just what to do.

Another thing that we’re thinking about looking at is developing DNA probes for all the molds, if they’re in the body somewhere. And the other one is looking for collaboration, to detect the mold toxins.

That was something that we wanted to do for the severely ill patients, but that never happened because the company that was going to do it went out of business.

There are a number of people who are trying to do that. We don’t have to re-invent the wheel. So they can look for the presence of the toxins in the patients.

 

Ben Howell: 

I know that mercury is quite a big thing in the CFS community, and so is, obviously mold. For mercury, is this hair testing?

 

Ron Davis: 

This is all hair testing. Of course, we worry about the validity of that. The value of hair testing is that it’s pretty painless on the patients and a patient anywhere in the world can send us a hair sample. It doesn’t have to get refrigerated. You just put it in an envelope and mail it. It’s very simple.

What we don’t know for sure is the validity of the hair. You have to worry about contamination of the hair. It’s out there, and so if you get something high, you have to worry about contamination.

If there’s contamination with mercury, I think that’s still a problem. That means the person was exposed to mercury. So that one doesn’t bother us so much. But for things like copper and zinc and other metals that might be in the environment, then you have to be careful.

So we were in some meetings with Erik Johnson about that. We actually visited him. He’s a person that can help us.

 

Ben Howell: 

As in – I don’t want to call him the mold guy, but….

 

Ron Davis: 

He’s had some experience. You always like to gain some experience from the patients. Sometimes they don’t use the right scientific terms, sometimes they misunderstand some of the scientific background, but you listen to them. And you try to figure out what it is that they’re experiencing. And you take them seriously enough that if you’re going to dismiss it, you should dismiss it because you can’t find any scientific evidence in testing that it’s there.

Until you do that, you have to listen.

And there very well could be. The mold toxins – the mycotoxins that they produce – are unbelievably powerful and very scary. Aflatoxin is the most mutagenic compound known. So they’re incredibly powerful.

There’s a reason – they make these things for their own defense. And they’re capable of making very large numbers of things under different circumstances.

It’s something that needs to be explored, and so far, I don’t see anyone really exploring the molds.

 

Ben Howell: 

I know there was Ritchie Shoemaker. And I know from reading Julie Rehmeyer and various people’s accounts of mold that it’s not a particularly easy thing at all to get rid of.

 

Ron Davis: 

No, it’s not easy to get rid of. And she’s another person that we’d like to work with. She’s been helpful as well. We just have to figure out what is the right strategy and what are the right people to do the study. It’s taken us a while.

It’s also a financial problem. Everything we do, when we start any project, the question is where is the money coming from.

You can’t rely on NIH grants because they won’t be awarded until you’ve almost finished the project. Because then they’ll know it will work.

The problem is that the amount of money that they have to fund research is so inadequate compared to the research capacity that is present in this country.

When I’ve looked at the research grants, I would say that probably 90% should be funded, but they’re funding at the 10-15% level. They like to say that the grants that don’t get funded weren’t good grants, but I don’t think that’s correct. They’re all good grants.

But the review committee were tasked with finding the best 10-15%. So it’s more of a personal choice than it is really the hard-core best grants. So that just makes it difficult to get research funding. Good ideas don’t get funded very quickly.

We will get the funding at NIH.  But I realize that it is going to take a very long time, because you have to have a lot already accomplished.

So if we show that the metabolic trap is real, then we can probably get grant funds to work on it. But you’ve already done most of the work.

But then, in fact, when you get a grant, it will surely be productive.

And so that’s one of the problems that they’re having, because of the lack of adequate research dollars at the National Institutes of Health. Overall, I think it’s a problem.

When the funding levels get that low, it makes the review committees very conservative. So if you have an exploratory grant where you might discover something really important – or then, it won’t.

This hypothesis testing when you have a track record and it’s been renewed many many times, we know they’re going to be productive – they have to give them the money, because we can’t take the chance of funding something that doesn’t work.

It’s the conservativeness of not taking chances or doing something new. And it happens with everybody when you start doing these reviews.

But it makes research progress slow. You want to take the big leaps. But it’s very difficult to get big leaps funded.

That’s why we are focusing on donations, because they can come in fast and move the research faster.

In the last round, we put a grant in. We’re putting a grant in in June, there will be two grants going in June. Every round, we’ll try to get a grant in. And then that adds to the funding from the patients.

But it has to be something that we know for sure is actually working. The last grant that went in was on the mercury, because we know that that’s working. It’s not a lot of patients. We’ll focus on collecting more patients and studying other aspects of that.

We will do some analysis of looking at the hair and the blood. And we’re also wanting to look at the cellular level. Because, for example, it’s how much mercury is in the cell that makes a difference. If it doesn’t get from the blood to the cell, it doesn’t matter that much.

The hair comes from cells, so it might reflect what’s in the cell better than the blood does. So we have to sort all this out. I think the way to do this is to look at the hair, the cells and the blood, in the same person at the same time.

So that will be the new area that we’re going to be exploring.

The mercury – some of it could be coming from old fillings. I’ve had my old fillings removed. I don’t think a lot comes from that, because my mercury ‘s not very high. Some of it comes from eating fish.

Are there other environmental things, that you can get exposed to mercury? We used to have mercury thermometers. We have one patient, I think they’re in Europe, that broke a thermometer in his backpack, and took out most of the mercury but continued to use the backpack. He’s very high in mercury, and it probably came from that. So it could be being exposed to a little bit of mercury.

 

Ben Howell: 

Fish contains selenium, and that is a trace mineral that is often found quite low in patients.

 

Ron Davis: 

It’s probably that the selenium binds to mercury. So you’re actually taking the selenium out. That’s probably good that it’s binding. That helps to sequester the mercury. But selenium is used for lots of things, and one of them is the conversion of T4 to T3. We know that these patients are low in T3.

What we don’t know is – we don’t have a connection between the T3 and the mercury. They’re measured independently. So we don’t know that the patients that have low T3 have mercury, and we don’t know that the patients that have mercury have low T3. That’s something that we could try to look at.

 

Ben Howell: 

I would like to see cellular T3 levels measured.

 

Ron Davis: 

It’s hard to do any of these cellular things because of sensitivity of methods. For most of these things, the methods are not sensitive enough. That’s why we need new technology to increase the sensitivity.

But boy, is that hard to get grant funds for. They’re very willing to fund you if you’ve already developed it. But having an idea of what would increase sensitivity which would have some risk – it isn’t getting funded.

 

Ben Howell: 

It kind of makes the blood measurements that we have seen all the more archaic.

 

Ron Davis: 

That’s correct. That’s one cell. And when you do a medical test, you take 10 ml. The difference between one cell and 10 ml is a tremendous difference.

We would really like to be able to measure it in one cell. We would like to do the metabolic trap in one cell.

No method is sensitive enough to be able to do that at the moment that we can find. But that’s what we like to think about, and see if we can come up with some idea about how to do that.

That’s our long-term sort of things. I didn’t cover everything that we’re going to try to do in the future.

A lot of this depends on the amount of funding that we get.

And also the problems in the funding is that sometimes we get donors that like to start a project. But often you don’t finish the project – the project leads to another idea, but it’s not quite a new project.

So how do you sustain some of these efforts, like the metabolic trap? We got funding to look at that. But now there are many other things that we have to explore in terms of, if it looks like it’s correct – how do we get people out of it?

It’s still the metabolic trap. It’s already funded. So how do you get new funding?

It’s a problem. Which NIH grants are great at – because if you establish something like the metabolic trap, then it’s easy to get renewals after renewals after renewals. So that’s when we have to get NIH grants in, when we have what looks like a potential breakthrough. And then get it supported by NIH, because they will sustain funding.

 

Ben Howell: 

So we just have to carry on as best we can, so that eventually NIH will step up to the plate and give us a nice fat grant.

 

Ron Davis: 

I hope so.

 

 

Related Articles: 

ME/CFS Research Review – December 10, 2019

 

Links on this page are in orange (no underlining).