SpecimenCollection Gak Ngerti

8/13/2019 SpecimenCollection Gak Ngerti

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Clinically RelevantClinically Relevant

Microbiology Starts at theMicrobiology Starts at the

SourceSource

Mike Costello, PhD, MT(ASCP)Mike Costello, PhD, MT(ASCP)

ACL LaboratoriesACL Laboratories

847.349.7403847.349.7403

mike.ostello!a"#oatehealth.ommike.ostello!a"#oatehealth.om

Mar$ Dikema%, MT (ASCP)Mar$ Dikema%, MT (ASCP)

A&&i%it$ 'ealth S$stemA&&i%it$ 'ealth S$stem

90.738.3890.738.38

m"ikema%!a&&i%it$health.or*m"ikema%!a&&i%it$health.or*


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Program Objectives

Emphasize that obtaining sensitive and specificmicrobiology results begins with the patient and not at thedoor of the microbiology laboratory.

Accentuate the importance of proper collection andtransport of specimens in both local and referralenvironments

Stress the importance of timely communication betweenthe Microbiology laboratory and those collecting specimens

Describe common pitfalls in specimen collection and

transport Discuss What rules or principles must be followed in order

to collect microbiology specimens which will accuratelyreflect the pathogenesis of the microbiological agent. (hurchD. !he Seven "rinciples of Accurate Microbiology Specimen ollection. . algary#aboratory Services Microbiology $ewsletter. %olume &' ))*+


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Introduction!he practice of sensitive' specific and cost effective clinical

microbiology is intimately tied to the submission and properhandling of optimal specimens for analysis. ,nfortunately'these aspects of clinical microbiology are not as criticallycontrolled as our laboratory assays. -t is our responsibility

to educate and notify our healthcare colleagues whenspecimens arrive at the laboratory that will yield inferiorresults.

uality assurance of specimen collection and transport is anever ending battle and re/uires long term commitment ofyour time and resources' but the end results are betterpatient care and a more rewarding e0perience for those ofus who wor1 in the microbiology laboratory.


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collected "ith a minimum o contaminationcollected "ith a minimum o contamination

as close toas close to

site o inection as possiblesite o inection as possible

Specimen Source ofContamination Storage andTransport Solution/Monitor Education

Urine Culture All non surgicalsamples becomecontaminated withurogenital flora duringcollection.Contaminatingbacteria will replicate ifspecimen is notquickly transferred to apreservative tube orstored (4C.

!ransfer urine toa Urine"reservative tubewithin #$ minutesof collection (goodfor 4% hrs. atambient temp.&ess optimal'storetransporturines at 4 C forup to )4 hrs.

"atients must beinstructed to properlycleanse the peri*urethralgenital skin area prior tocollection of the mid*stream portion of theurine stream in order toget an accurate urineculture result. Use ofurine preservative tubes.

"romptfeedback toindividuals orsites whocollected urinefor culture.Urinepreservativetubes shouldbe used whenappropriate.

+lood Culture,bacterial,mycobacterial,fungal

-mproper cleaning ofskin or catheter prior todrawing specimen.!ransfer from "

tube to blood culturevial.Collection fromcatheter.

Ambient. /ust beincubated inautomatedsystem within #)

hours.

0ngoing educationprogram. /onitoringcontamination rates.&imit use " tubes.

1o not draw from catheterunless specificallyrequested (protocol2discard 3 cath. volume2then one culture set fromcatheter and one fromperipheral.

!imelyfeedback toindividualswho collected

specimen.


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$rine Culture Contamination Rates

+ri%e Cltre o%tami%atio% rates (-bateria at -00,000 C+) shol" be /0 A" 2"robe study (%alenstein " Meier 3. ,rine culture

contamination4 a ollege of American "athologists 2"robes study of contaminated urine cultures in 5)&

institutions. Arch "athol #ab Med. 655786469265+.. &9) participants collected information of 6**')9: urineculture specimens8 ).6; were considered contaminated(


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%lood Culture

!wo sets of blood cultures should be drawn.$umber of sets positive correlates with truesepsis (e0cept for coagulase negative Staph?+(lin Microbiol. =ev 654:7727)' ))&+

atheter drawn blood cultures atheter drawn blood cultures are e/ually li1ely to be

truly positive (associated with sepsis+' but more li1ely tobe colonized (@ lin Microbiol 9749959' ))6.+ ne drawn through catheter and other though vein ""% )f

5&; Both drawn from catheter ""%(positif predi1tif value+ )f

20 Both drawn through vein ""% of 57;

Study of positive coagulase negativeStaphylococcus cultures and sepsis(lin -nfect Dis.954999' ))C.+


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%lood Culture Contamination Rate%y Service &ra"ing Culture

+lood Cultures Collected +y -ndicated taff!ype (5

6o. of&abs

/ean +lood Culture Contamination7ate (5

Dedicated phlebotomy staff

$*)3 84 9.):);*:3 #): 9.$)

:;*#$$ #)$ 2.84Medical technologists or technicians

$ #;3 9.)3#*#$ ##9 ).83

##*#$$ ;$ 2.!"onlaboratory staff

$ 9; ).#:#*3$ )39 9.$$

3#*8$ 9; 9.4$8#*#$$ #: 4.2#

+erkeris & ?alsh, "6 @alenstein. !rends in +lood Culture Contamination.Arch "athol &ab /ed #)8'#)))*#)84, )$$3

What is an Acceptable Blood ulture ontamination =ate for Four #ab??


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Blood Culture Contamination in PediatricPatients

Young Children and Young Doctors

%ariable !rue "ositive 3alse "ositive "redicative %alue ofa "ositive =esult

E0perienced physician2older

child

8 74 0.23

E0perienced physician2younger

child

2 2 0.2

-ne0perienced physician2olderchild

9 28 0.37

-ne0perienced physician2youngchild

382 0.37

!otal 20 78

"ed -nfect Dis. ))&' *4&662&6C.

Foung hildren G 629* monthslder hildren G


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'hat is an (acceptable) blood culturecontamination rate*+

Contamination 7ate"opulation 6o. of &abs )3

th"ercentile 3$

th"ercentile (/edian :3

th"ercentile

Adults 9); ).)9 ).8) 9.%

6eonates )34 $.:3 ).$% 4.):

All "atients 93; ).#3 ).%8 9.;:

+lood culture is considered contaminated if # or more of the following organisms were identified

in only one of a series of blood culture specimens2 coagulase negative taphylococcus,

Propionibacterium acnes, /icrococcus spp., @iridans group treptococcus, Corynebacterium

spp., or +acillus spp. (not B. anthracis

CA" B*!racks (#888*)$$9 /edian contamination rate of ).8)5

?hat should your blood culture contamination rate be

#. tatic model. et a contamination rate (D95. 7ange ).)95*9.%5 Adults2 $.:35*4.):5

6eonates. 1efine an Eacceptable rateF and institute correct measures when rate drifts above

critical value

). Continuous Buality -mprovement /odel. et a rate that at which )9 can achieve, D).35.

0nce 835 of units achieve this rate lower it to ).$5. trive to be in the top #$ percentile

Ber1eris #H' @A !owore1' MI Walsh' "$ %alenstein. !rends in Blood ulture ontamination.Arch "athol #ab Med 6546265C' ))*


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Principle #1 !he specimen must be collected!he specimen must be collected

"ith a minimum o contamination as close to"ith a minimum o contamination as close to

site o inection as possible ,cont-.site o inection as possible ,cont-.

Specimen Source ofContamination Storage andTransport Solution/Monitor Education

7espiratoryCulture

-mproper mouthcare prior tocollection ofspecimen.&ack of deepcough to obtainlower respiratorymaterial.

Ambient for %hours.7efrigerated )4hours.omeorganisms, suchas Haemophilusinfluenzaeare

susceptible todrying or lowtemperature.

/onitor 5 reGected sputum.5 with oral contamination(epithelial cells2 multipletrep species, usually inclumps on gram stain andculture results.

putum culture @s. blood

culture results

All sputum samples arecontaminated to varyingdegrees with oropharyngealflora. 7insemouth with sterilesalinewater immediatelybefore eHpectoration reducesnumber of contaminatingbacteria. !imely feedback to

individuals who collectedspecimen. putum samplesof D) m& should not beprocessed unless obviouslypurulent.

?oundCulture

-mpropercleaning ofwound site prioror collection.

-n transportcontainer.Ambient for nolonger that )4hours.

/aHimiIetransport time.

6umber of squamousepithelial cells @s. "/6sseen on


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Respiratory Cultures

ommunity Ac/uired "neumonia J Sputum re>ection rate andculture correlation with gram stain *C; of all samples were >udged to be of good /uality. "resence of a (predominant morphology+ "M on Hram stain was

predictive of whether the sputum culture could demonstrate apathologic organism. -n the presence of a positive "M' 7&; of culturesyielded a pathologic organism' while a positive culture was obtained in

65.*; of Hram stains without a predominant organism. S.pneumoniaewas the most common infection' growing in **.:; ofpositive sputum cultures.

!he sensitivity and specificity of finding Hram2positive diplococci for apositive culture of S. pneumoniaewere &); and 5:.&;' respectively(Arch Intern Med. ))C86&C46:*26::' 67):26766+

%entilator associated pneumonia (%A"+ J appropriate specimen

Blood cultures highly specific but not sensitive (positive in K6); of%A"+ uantitative cultures of lower respiratory tract specimens show a

closer clinical correlation than sputum subcultures (linical Microbiol.=ev. 654&9:2&*:' ))&.+


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/iral Respiratory Cultures Collect Sample 0rom Site o Inection

Comparison of nasal swab, nasopharyngeal swab, and nasopharyngeal wash specimens with an

expanded gold standard in the Quidel QuickVue influenza test

No. of positive samplesno. of samples !"#

$pecimen %ype $ensitivity $pecificity &ositive &redictive Value Negative &redicative Value

Nasal $wab '()* !+# '(' !*(# (-+' !# -/+- !#

Nasopharyngeal Swab 50/59 (85%) 50/51 (98 62/71 (87) 112/122 (92)

Nasopharyngeal 0ash '-)* !(*# '-' !*# (/ !+# -/1- !'#

2 Clin 3icrobiol. //(4 ''5(16('-

Low do you 1now that an ade/uateSpecimen was submitted for rapidE-A assays???

!hroat swabs are even worse

S l i i


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Samples or &iagnosis o/iral Respiratory Inections

$ung biopsy

%ronchial al&eolar

la&age/'ash/brush

"asopharygeal secretion

"asopharygeal 'ash

(nduced sputum

"asopharygeal s'ab

"asal 'ash

Throat s'ab

)adeno&irus only*

Sali&a

%lood+

SputumSputum

1LAM-A 0-A Culture

LRTC*

present

LRTC cells

absent ,eagentCost1LA NCulture NNM-A NNNNN

0-A NNNN7!*"C7 NNNNN

"C7Costeffort ofcollection

ource ofinfection

,emote

sampling

-iral Titer

(

-iral Titer

$01

Sample2tility

as$

'ar"

#=! G lower respiratory tract cells(columnar epithelial cells' alveolar macrophages+

Site of

infection


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Submit Specimens 3"ot S'abs

"ancy Cornish MD

'''.cap.org


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Sin and Sot !issue ,'ound.Cultures

ollect with steel (needle aspirate or scalpel+ Discourage the use of swabs -f infection $! suspected' D$N! culture Het infected tissue or body fluid O discourage swabs P

2use something sharp ( syringe' scalpel' etc + 2close doesnNt count DonNt culture the surface Q get deep infected sample =emove needles Q send capped syringe with aspirate Share specimen4 Microbiology2Surgical "ath2ytology

#abel specimen and site accurately Hive appropriate history(Mat1os1i . Sharp SE' Iis1a D#. Evaluation of the Score and 9C Systems for cost2effective and

clinically relevant interpretation of wound cultures. @ lin Microbiol ))&8CC467&5267:+

d t


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order torecover the pathogen,s. o

interest

Specimen 0ptimal Time Comments

Urine Lirst morning specimen preferred. 0r not have urinated in severalhours

+lood Culture Collect prior to administration of antibiotics.Collect )*9 sets of blood cultures from differentsites. -f suspect bacterial endocarditis and

initial cultures are negative at 4% hours thencollect )*9 additional cultures from differentsites.uspected bacteremia or fungemia withpersistently negative blood cultures

-nterpretation of one positiveculture problematic, especially ifisolate is coagulase negative

taphylococcus.

Consider laternative blood culturemethods dsigned to enhancerecovery of mycobacteria, fungi,and other rare and fastidiousmicroorganisms

AL+ Culture !hree consecutive specimens collected %*)4hours apart, with at least one being an earlyA/ specimen

putum not saliva


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collected at the optimal time,s. in orderto recover

the pathogen,s. o interest ,cont.

Specimen 0ptimal Time Comments

0va and

"arasites

?ait #$ days if barium or oil present.

Lor multiple samples, collect every other day.

"lace stool in preservative (#$5

formalin, "@A, AL, McofiH within

one hour of collection.

-nstruct patient.

tool Cultures 7ecommend ) samples on consecutive days.

"rior to 9 days post admission.

"lace in enteric preservative (Cary*

+lair immediately.tool specimens that are obtained 9

days after admission are not usually

helpful for the diagnosis of hospital

acquired diarrhea

+lood "arasites Collect during a febrile episode or every ; hours

for a )4 hour period.

ubmit finger stick !hick P !hin

slides or peripheral blood in an

M1!A tube within )4 hours. tore at

ambient temperature.@iral Culture Collect as soon after onset of symptoms as

possible.

!he first 9 days is best.

i i l i i i h


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Principle #4 3 suicient 5uantity o thespecimen must be obtained to perormthe re5uested tests

Culture !n!"u"

#e$u!re"ents

Co""ent

7lood Culture -/ ml of aerobic5 -/

ml for anaerobic

bottle

$ensitivity of a blood culture is directly related to the

volume of blood submitted. %wo blood culture sets !-/

m8 in both aerobic and anerobic bottles# before

administration of antibiotics is *" sensitive !2. Clin.

3icrobiol. -** 1(4 ()+6((-#.

9ne swab for

multiple

cultures

: separate swab!s#

for each culture

;nough material must be submitted for gram stain, if

re


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%lood Cultures

6olme o& bloo" "ra5% is the si%*le mostim1orta%t &ator i%&le%i%* se%siti#it$. Asingle set for an adult blood culture consists ofone aerobic and one anaerobic bottle. ptimally0 mL o& bloo" shol" be i%olate" i%to

eah bottle. %olume of blood for a pediatricculture can be related to the infants weight

Solitary blood cultures should be less than *;(Arch "athol #ab Med. ))6 6*465)265C+

-f only enough blood can be drawn for one bottle'

inoculate the aerobic bottle. &CC positive blood cultures' *5.7; from both bottles'5.7; from aerobic bottle only and 6).C; fromanaerobic bottle only (@ -nfect hemother 54:' ))9+.


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Recommended Pediatric Blood Culture Volumes By Patient WeightWeight(KG) ofPatient

Weight(LB) ofPatient

MinimumVolume(mL)

OnePediatricBottle

Two AdultBottles(aerobic

andanaerobic)

25.0 Kg >55 Lb. 20.0 Ml No Yes (10 mLin each)

Pediatric %lood Cultures 6/olume


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Specimens.

T(SS2ET(SS2E 4$2(D4$2(D

pecimen siIe of pea or largerpecimen siIe of pea or larger

Di&ideDi&ide

Anaerobic transport tubeAnaerobic transport tubeKoldKold upright5upright5uncap,uncap,insert specimen andinsert specimen andrecaprecap

AnaerobicAnaerobicCultureCulture

>eep moist by>eep moist byadding #adding #**) m&) m&sterilesterilesalinesaline

Aerobic cultureAerobic cultureand


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3cceptable Specimens 0or3naerobic Culture

Site 7cceptable Specimens 2nacceptableSpecimens

Abdomen Peritoneal fluid obtained by needle and syringeAbscess aspirate obtained by needle and syringeBileBiopsy material surgically obtainedAnaerobic swab surgically obtained

Aerobic swabs

Body Fluids Ascitic fluid, bile, blood, bone marrow, CSF, pericardial,

pleural, seminal, synovial fluid, throacentesis, transudatesBone and joint Aspirate obtained by needle and syringeBiopsy material surgically obtainedAnaerobic swap surgically obtained

Superficial materialcollected with swabs

Central nervoussystem

Abscess aspirate obtained by needle and syringeBiopsy material surgically obtainedAnaerobic swab surgically obtained

Aerobic swabs

Female genital

tract

Culdoscopy specimens

Endometrial aspirate obtained by suction or protectedcollectorAbscess aspirate obtained by needle and syringeBiopsy material surgically obtainedAnaerobic swabs surgically obtainedIUD forActinomyces species

Vaginal or cervical swabs


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3cceptable Specimens 0or3naerobic Culture

Site 7cceptable Specimens nacceptable Specimens

Head andneck

Abscess aspirate obtained by needle and syringeafter surface decontaminationBiopsy material surgically obtainedAnaerobic swab surgically obtained whenaspiration is not feasible

Throat or nasopharyngeal swabsGingival swabsSuperficial material collected with swabs

&ungs Transtracheal aspirateMaterial from percutaneous lung puncture

Biopsy material surgically obtainedBronchoscopic specimen obtained by protectedbrushThoracatomy specimenAnaerobic swab surgically obtained

Expectorated sputumInduced sputum

Endotracheal aspirateBronchoscopic specimens not speciallycollected

Soft tissue Aspirate obtained by needle and syringeBiopsy material surgically obtainedAspirate from sinus tract obtained by needle and

small plastic catheterDeep aspirate of open-wound obtained throughdecontaminated skinDeep aspirate of surface ulcer obtained throughdecontaminated skin

Superficial material collected from skinsurfaces or edges of wound

Urinarytract

Suprapubic aspirate Voided urineCatheterized urine


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devices and specimen containers mustbe used to

ensure recovery o all organisms

Culture/S!tuat!on Co""ents

:naerobic Culture :naerobic cultures are best collected with metal !needle aspiration or

with a scalpel#. :spirates of pus or fluids could be left in syringe if

not a long distance transport. : large piece of tissue )6-/ mm will

protect anaerobes in center. $pecimen received in aerobic transport

media. $tuart>s and :mies media will allow for isolation of facultative

anaerobes !:mies giving slightly better yields#. ?se of true anaerobictransport media will result in the best yields of all anaerobes. Consider

re@ection of swabs not in anaerobic transport.

Chlamydia or AC Culture $pecimen received in N:% transport tube can not be cultured.

Collect Chlamydia in 36', ?%3.

Collect AC culture in :mies B charcoal and or transport immediately.

to lab at ambient temperature for immediate plating.

%issue sent in preservative 7acterial culture ordered on tissue placed in formalin. Culture is notan option. e


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Recovery o 3naerobic %acteria Placedin in 3erobic83naerobic !ransport

Media

%" G opan %i2"a1 Amies Agar Hel collection and transport swabsSSS G Starple0 StarSwab --'"A G BB# "ort2A2ult

Low Does !ransport !ime Affect Fields?

R 3 bi % t i Pl d


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Media ,Cont.


R 3 bi % t i Pl dff


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Media ,Cont.

@ lin Microbiol. ))6495 9::297)


devices and specimen containers must


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devices and specimen containers mustbe used to

ensure recovery o all organisms


Viral culture sent in

bacterial transport media

Viral culture sent in 7acterial transport media. e


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devices and specimen containers must beused to

ensure recovery o all organisms ,Cont.


&neumocystis @aroveci!carinii#

7ronchoscopy or induced sputum preferred. &lace sample in a sterile,tightly capped container and storetransport refrigerated within '

hours

$kin parasites &lace skin scraping in a clean dry container, cap tightly and transport

to lab within ' hours at ambient temperature

3ycoplasma pneumoniae

Culture

espiratory sample or C$= in sterile cup. %ransfer specimen into 36'

or ?%3. $toretransport at 'FC. %ransport time should not exceed 'hours.

Consider amplified nucleic acid assay

7lood culture from

Heparin or ;D%: tubes

Heparin is toxic to many organisms.

Increased risk of contamination during transfer.

Suggested !ransport Media 9eneral


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Suggested !ransport Media 9eneralComments

Medium 2tility Comments

tuartOs /edium /ost aerobic and some facultativeanaerobes.


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Principle #: Collect all microbiologytest samples prior to the institution o

antibiotics

Specimen Comments

+lood Culture Collect two sets at same time from different sets. 10 60! collect both sets from

the same site (assessment for contamination

Kair, skin and nailsLungal Culture

Collect before antifungal therapy or discontinue treatment for at least 3 days.

Urine Culture Antibiotics may cause a transient decrease in bacterial concentration resulting in a

false negative report

Principle #; !he specimen container


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Principle #; !he specimen containermust be properly labeled and sealed

prior to transport

S!tuat!on Co""ents

:ny unlabeled or improperlylabeled specimen sent to the lab

3ay decide to have the individual who collected thespecimen to label specimen. 8abel only on bag not allowed.

:ny leaking container e@ect.;ach sample must have at least

two uni


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or ma>imi=e transport media- !here isal"ays some

loss o viability during transport

Specimen Ma6imum Transport Time not inTransport Media

Ma6imum Transport time in Transportmedia

All pecimens "rocess within one hour "lace in transport media. tore andtransport as recommended

tool Culture ) hours Cary*+lair 4% hours


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?nvironmentally 0ragileOrganisms

rgan!s" ost &!'ely Spe!"en Co""ent

Shigella spp. $tool Immediate processing recommended

N. gonorrhoeae Aenital $ensitive to cold. Need )6-/" C9.

Immediate processing recommended

N. meningitidis C$= $ensitive to cold. Immediate processing

recommended

H. influenzae C$=, eye, ear, throat $ensitive to cold. Immediate processing

recommended

A monitor??

Principle #@ Special


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Principle #@ Specialhandling8Collection instruction must be

ollo"ed

Specimen Special (nstructions

+lood Culture +eware of decentraliIed phlebotomy


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Principle #@ Specialhandling8Collection instruction must be

ollo"ed ,Cont-.

3irst' communicate with those that are doingcollections.

ollection instructions are written and available.

Het involved with nursing orientationQeducationdays and as1 to have the instructions given out8poster board learning8 /uiz or competencies.

!al1 to providers when there are problems with

specimen collection8 they sometimes do not 1nowthey could do it better.

or Ordered !est


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or Ordered !est

Specimen "ot acceptable Specimen 7cceptableSpecimen

Comments

Lungal +loodCulture

7outine blood cultures fordetection of Kistoplasmacapsulatum, Blastomycesdermatitidis, Coccidioides immitis,or Malassezia furfur

Lungal +loodCulture

7outine blood cultureswill detect maGority ofpatients withcandidemia.

Lungal7espiratorypecimens

putum swabs for AL+ or fungus AL+' putumLungus' putum,Cryptococcus only.!hrush

6eed tissue to make adiagnosis of fungalpneumonia.1iagnosis of thrushusually only requiresgram stain.

AnaerobicCulture

Autopsy material, respiratory,decubitus, environmental, stool,urine (not aspirate, vaginalsecretions, superficial wounds

ee Anaerobicspecimen table

"olymicrobial

lide for gram

stain


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Criteria 0or Rejection o MicrobiologicalSpecimens

riteria for re>ection must be readily available andlaboratory specific

,nlabeled or improperly labeled specimen "rolonged storage or transport

-mproper or damaged container Specimen received in fi0ative ropharyngeal contaminated sputum Duplicate specimens stools' sputum+ within a C hour

period. E0ceptions cleared by the laboratory Specimens unsuitable for culture re/uest (anaerobic culture

from not acceptable source' urine from 3oley catheter+ Dry Swab C2hr collection of urine or sputum for A3B or fungal

culture ther criteria specific to your laboratory


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Cultures !hat Should Include a 9ramStain

S3 or sterile body fluid (cytospin+

Eye

"urulent discharge

Sputum or transtracheal aspirate All surgical specimens

!issue

,rethral e0udates (male only' intracellular

gonococcus++ %aginal specimens

Wounds


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Summary

"ublish specific rules for specimencollection !here will be e0ceptions

Ma1e physician or healthcare provider aware ofimplications of culturing suboptimal specimens

ommunicate' communicate'communicate

=eal time feedbac1 ontact the health care wor1er who collected

the suboptimal specimen


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References linical Microbiology "rocedures Landboo1. nd Edition. .

LD -senberg ed. ASM. umitechs. ASM "ress. Wash. D.

Manual of linical Microbiology' 5th Edition. ASM "ress.Wash. D. )):.Miller M@.

A Huide !o Specimen Management in linical Microbiology.ASM "ress. Wash. D. 6555.

Documents

SpecimenCollection Gak Ngerti