lf Tachypnea

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         may show patchy Infiltrates, in-
         creased anterior-postenor diameter,
         hyperinflation, flat diaphr'lgm, and
         coarse streaking (Figure 2).
            Respiratory distress syndrome,
         also known as hyallne membrane
         dlsease, occurs p r ~ m a r ~ in pre-
                                       ly
         term Infants The ~nc~dence less1s
         than 1%In term 1nfants,l5 whose
         nsk 1s Increased by chonoamnionl-
               ,
         t ~ s preclpltous del~very,caesarean
         dellvery before 39 weeks, or mater-
         nal dlabetes 'I6 The pnmary cause
         of rcsplratory d~stress    syndrome
         (RDS) 1s surfactant d e f ~ c i e n c ~ , ~
         wh~ch     results In atelectas~s,VIQ
         m~smatch,and hypoxlc vasocon-
         stnctlon Any process that reduces
         surfactant can lead to RDS As
         w~th    transient tachypnea of the
         newborn, RDS may mlmlc bac-
                                         lly
         lerlal pneumonia ~ n ~ t ~ aAfter
         the d~sorder     progresses over the
         first three or four days of hfe, dl-
         uresls may p a n t towards recovery
         Chest films class~callyshow a unl-                                                                            hypertension of   tile   newborn   ,
                                                                                                                                                                  ,
                                                         .           .
                                                                     .        . ,                                                                             .       .
         corm ret~culonodularappearance             ,


         (ground glass) wlth air broncho-                                                                                                                                 .    .
                                 and
         grams, hypolnflnl~on, atelectas~s , -
         (Figure 3)
                                                                              .                 ~eningitis
                                                             .            ,         ,                                      '     .
         Cardiovascular
         diagnoses                                               '
                                                                 ,       ,,             .   .                                                                             .,

         Co~~gcnital  heart tlisease ant1 pcr-           -
                                                        - -
         sistcnt pulmonary hypertension of
                                                        Metabolic
         thc ncwborn are the primary car-
         diovnscular causes of nconatal
                                                                                                Hypocalcemia       , '
         respiratory distress.
                                                                                                Metabolic acidosis (any source)
            Congetlital heart disense. Ccn-
         tral cyanosis tlespitc atlcquate ven-                                                  Narcotic-induced respirato~j depression
         tdation no st often results croln                                                      Methernoglobinemia         .- --   -
                                                        --
                                                         .
                                                         .
         congcnilal heart ~liseasc.  Murmurs            Hematologic                             Po!ycythemia
         limy hc abscnt and l l ~ c clectrocar-                                                 Anemia
                                      1
         diogram may he nor~llal.1 1 ccttaiu            Source: Kali'!iinkel J (ed)' and Behrrnan RE, Kliegman RM, Jenson tiB (eds)"
         collgenital disorders, such as conrc-
                                                                         NEONATAL RESPIRATORY PROBLEMS



                                         FIGURE 1




 tation of the aorta, the typical pat-
 tern of higher blood pressure in the
 lower extrcmities than thr upper
 exvemities rnay be reversed. ,      ,

    If respiratory distress accom-
panies central cyanosis, a hyperox-
ia challenge test is recommended to
scrccn lor righcto-left shunting, a
common finding in many heart de-
fects. The traditional method of
perlorrning the t e s t i s to obtain
room air baseline arterial blood gas
(ABG) measuremcnts, which typi-
cally show arterial oxygen tension
(f60,) l e ~ s  than 60 rnm Hg The
patient is then given 100% oxygen
by oxygen hood for 10 minutes
and ABG measurements are re-
peated. If the PaO, remains less
rhan 150 mm Hg, further cvalua-
tion with echocardiography is rec-
ommended." A PaO, greater than
LOO mni Hg aItcr the patient has
received 100% oxygen is consistent
wirh alveolar hypovcntilatio~l     and
V I Q mismatching, indicating a
pulmonary cause.
   Sunultaneous preductal and
postductal pulse onimetry to mea-
sure arterial orygr11 saturation pro-
bides a contemporary alternative to
the ABG method 01 detecting right-
to-lplt shunting. tvleostirements of
SAO, from an oximctry sensor on
      t
tl~c~ght     hand thar arc xilore than
 LjSt highcr ihan readings from a
scnsnr on the foot indicate shunt-
ing.'"As WIIII hloud gas tneasurc-
Inelrts, pulsr oximetry readings
.;honld br lakrn while the infant is
rcceiring 100'% ciqgen. The value
of pulse oximctry has hcen con-
I ~ ~ r n 111 asy~iptounnticinfanls as
          c~l
well as those wlh symptoms. A re-
rent stl~dyfound that when SAO,          Radiograph shows patchy infiltrates,coarse streaking, and hyperinflationof the lungs.
                                         COII~CSY 01 Gael J Lonergnn, lrlD


                                                                                     l i n e 2 1 0 4 C0PITFF.IPOHARY PEDIATRICS 65.
NEONATAL RESPIRATORY PROBLEMS




                                                                                        Respiratory distress requires con-
                                                                                        current investigation and manage-
                                                                                        ment; correctingcyanosis and as-
                                                                                        sisting ventilation are the initial
                                                                                        concern even in the absence of a
                                                                                        definili\-e diagnosis. Positive pres-
                                                                                        sure ventilation (PPV) at. 4 0 to
                                                                                        60 breaths a minute with 100%
                                                                                        oxygen should be started if the
                                                                                        newborn's respirations are gasping
                                                                                        or absent d e s p i t e 3 0 s e c o n d s
                                                                                        of drying, warming, and stimu-
                                                                                        lation.' T h e oxygen flow rate
                                                                                        should b e 5 to 10 Uniir.. Un-
                                                                                        checked hypoxia causes p u l -
                                                                                        monary va5oconstriction and. ex-
                                                                                        acerbates hypoxemia. I f PPV is
                                                                                        required for longer than a few
                                                                                        minutes, an endotracheal tube
                                                                                        and an orogastric tube for sto~nach
                                                                                        ventilation should be inserted.
                                                                                           If the infant has central cyanosis
was greater than 94% in asympto-               right-tm-left shunting through the       but no apparent respiratory dis-
matic infants before discharge, its            patent ductus arteriosus and fora-       tress, give free-flow 100% oxygen.
negative predictive value in ruling            menovale. Central cyanosis may           If cyanosis persists beyond one
out congenital heart disease was               accompany the,uewbom's respira-          o r two minutes, consider PPV.
LOO%.^^                                        tory s$nptoms. PPHN may be an            Flyperoxia challei~ge      testing should
   Right-to-left shunts sonletimes             idiopathic primaly disorder or the       b e p e r f o r n ~ e dif PPV d o e s n o t
occur with noncardiac disease,                 result of another conditibn that         reverse central cyanosis.
however, giving a false-positive rc-           causes hypoxic vasoconstriction.            Take a brief history after initial
sult on the hyperoxia challenge                Because right-to-left shunting is        stabilization efforts if this has not
test. E x a ~ i i p l e sinclude hypo-         present, the hyperoxia challenge         already been done. The history
glycemia, asphyxia, pneumonia, as-             test will b e abnormal. A clue to        should focus o n marern;il risk
piration, diaphragmatic hernia,                PPHN: The severity of hypoxia is         factors such as fever, meconium,
pullnonary hypoplasia, persistent              out of proportion to findings o n        diabetes, colonization wilh group
pulmonary h)l>ertension,and poly-              chest films. Echocardiography            B Strrptucuccus, narcotic analge-
cythemia. Even if a noncardiac                 confirms the diagnosis.                  sia, and a family history of con-
source is suspected, echocardiog-                                                       genit;il dcfccts. Antenatal ultra-
raphy is recommended to exclude                Evaluation and                           sonogrnphy findings should be
cardiac defects.                               management                               reviewed. Physical examination
   Persistent prlllt~onary11)yerterl-          Figures 4 and 5 s u ~ n m a r i z ethe   locused on the oropharynx and
sion of tlre newbonr, or PPHN,                 evaluation and management of             nasopharynx, neck, lungs, heart,
arising from ab~lorlnallyhigh pul-             term and near-tern] infants who          and abdomen can exclude many
                                    e
monary vascular r e s i s t a ~ ~ cthat        exhibit tachypnea, grunting, Har-        o f the system-based diagnoses
f,iils to dccline after birth, lends to        ing, retractions, or central cyanosis.   listed in Table 3.


6 6 COFII~MPOPAHY
 5               2EDlATRlCS    Vol E l . :,lo. 5
FIGURE 4
Evaluating and managing the term or near-term infant with tachypnea,
              ,
p ~ m t i n gflaring, or retractions~'      .  .
                                                                                  ..
                                                                                   ~.    .;



                                                                                                    ,        .


                                                                                                                 .   .




   ',Treat any life Uireatenrng
     condit~ons  (tens~on
     pnei~mothorax,septic shock)
                                     -    Perform r ~ s factor assessment and
                                                        k
                                                           t
                                         focused exam (oronasopharynx, neck,
                                                lungs, hcart, abdomen)
                                                           4                        t
                                                                Symptoms p e r s ~ slonger than 20 min
                                            Add oxygen rf not tone before
                                             Start lV and beg111
                                                               ant~biot~rs
                                                           I

   Laboratory studies                    Chest radrograph pattern                      Electrocardiogram pattern
   Complete blood count [anenira,        Asplratiori                                   Axis devrat~on
   polycythema rlnfrrtion)               Air leak 01 p~~eul~rothorax                   Ventrlchlar hypertrophy
   Broodculture (rnfect~on)              Cardlac s~ihouette                            PeCorm echocardiagran~~f ECG IS
   GItiro:e (hypoglyremrn)               D~aphragmat~c  her~ila                        abnormal
   A ter~dl bi3od gases (ac~dosls,       Pneu~r~on~a
   hvpoxr.1111d)                         Resp~ratorydistress syndrome
                                         Transient lachypnea of newborn

                    I                                       I                                            1
                                             Treat identified cond~tions


                                                                       ~r
                                     If no cause apparent, c n n s ~ ltransfer usrng
                                                   Rulc of Two Hours'
                                        no Imprmlemcnt after 2 h'

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                                                                                           NEONATAL RESPiFIATORY P R O B L E M S




 1notlcr:lte symptoms have a high
 risk of aspiratic)n; withhold reed-
 ing. The hest choice of intr:lvenous
 maintenance Iluld for the first day
 of life i n term infants IS D,,W at
 80 inykgklay
       Giv~ng            s~1pplcinent.11oxygen to
m a i n t a i n pulse o x i ~ n e t r y          values
 hifiller than 90% is usually sulli-
cicnt for less scvercly ill infants. If
 the child neetls m o r e than 1- to
6 U m i n by nnsal canula, aclminis-
tration by oxygen hood is Ilclpful.
FiO, conccntmtions can vary fro111
0 . 2 1 to 1.0 inside nn oxygen hood
a n d s l ~ o u l d incasured as near
                            be
the nose as possible. Tank flow
rates greatcr than 7 U m i n are re-
cloirccl to wash out CO, from the
oxygen hood."
     W h e n respiratory lail~rrcoccurs
deslxtc illitin1 stabilization, endo-
trachcnl intuhntion a n d inechun-
                                                             Bowel gas patterns can be seen In the upper left lung flelds of the radiograph
ical ventilation can reduce 1nort;ll-
                                                             Courtesy of Oorotliy I Bulas VO, C h ~ l d r c n N?lionll Vedc?l Csntcr, Wlsh~ngton,D C
                                                                                                            s
ity, averting o n e cleat11 for cvcry
f o u r p a t i e n t s trcaretl ( n u m b e r
nccclcd to rreat = 4)." Rcspirntory tulle and orogastric evacuation of dilficult clccisions regarding whethcr
fL1ilurcis tlcfined as persistent ap- ~t0111acI1                       COLltCIItS.                                        to transfer infants in respiratory
nen o r tlctcriorating blood gascs                          Medications s u c h as prosta- distress to a n N l C U . T h e rule
o n 100'%1oxygen (PaCO, greater glandin El (Prostin VR Pediatric) or r e c o ~ ~ ~ u ~ translcr if:                                             ends
111;111 00 111111 Hg, PaO, less than                      natural bovine pullnonary surfae-                                   two hours have passed without
50 n11u Hg, antlpEl less than 7.25)."" tnnts such as heractant [Sunnnta) improven~ent
      (:~-rrai11         ciiuscs of respiratcvy clis- or calbctnnt (Infasurf) should he                                                                   is
                                                                                                                              the chest r n d i o ~ r a p h ahnonnal
II.c\\       h;rvc. KT). >pecific treatmenis. used in consult;ltic~nwith a neonat- a the infant's respiratory condition
C l~o:~nal             ,111csi:lrccluires use of an ;llogist anel in anticip,ltion of trnns- cletcriorates or
01-;11 ,lirw:iy. Iiobin synclromc is                      (erring [he infant to a neo~latalin- a mvrc t l ~ a n                              40°h o x y g c ~ ~required
                                                                                                                                                             is
~ r ~ , . i ~In. lplncing thc nclvhorn ill t c ~ ~ s i v e facility The 1iigl1 rate to maintain 95% SAO,.'
                    i.t                                              care
l l i ~ ,p1-c~1ic~       1xhirio11;111d111;ry rcq~~irc.of signilic.lnt adverse effects asso-
i ~ i s c r ~ i oIn a n.\.scrph;l~yny,eal
                        , \                         tuhc ci:lted \\:it11 tllesc ineclications To wait or act?
to l,yp:15s t l ~ c~rclropositionccl clictates caution.                                                                    To I-etul-nto the cll~cstiori~)c~,ccl     in
I ~ I I I , ~ I I L ' .P n c u ~ n o ~ l ~ o isa treated
                                             r s                                                                                                   ;n
                                                                                                                           the case hiirt~ly ~ h bcgiilning of
                                                                                                                                                          e
1))' ; ~ \ p i r ' ~ L i l v i ~ l l:I 2 1 - o r 23- When to transfer
                               ol~                                                                                         this article: Is continuccl ol)scrva-
yl~gc             IICCCIIC , I L I IIV lo11r111    inLc~- Baseel on clinical experience since ti011 or intcrvcnlion ~ l l c                                 hcst choice
ccrstnl sl7ac.c in he nnLc~iorasi113ry 1 9 7 3 , ~ h I n w : ~P c r i n a t a l Carc for bnhy I<. C . ? bier u n c v c ~ i t f ~ n -l
                                                                             c                                                                                      a~
linc. Llinplirng~nil~ic               hernia recluircs I'rogram has clcrivcd a "rule of tlvo tcnal;ll course and v.igin;il clelive~y
~ ' l ; ~ c c , m c n t a n c n t l o t r a c h c a l 1l~)ars'' ~ u i c l ep h y i i c i n ~ ~ s
                            of                                       io                                       f;icing I-c,ipirntory r a t e of 6O/lnin, i~ncl
                                                                                                                                              ~ ~ ~ , I I ~ I I ! I I L . , /~!I,:C. 72
                                                                                                  NEONATAL RESPIRATORY PROBLEMS




                                       ~
              C n n l ~ n u r d J r o npogr 10


    ihr mnyircy contracapli~r,      ccfiily l l c c ~ . ~ i b f r
    on drugs~ore  shclves, (For background on this
    controversy, see "Updates" in the January 200+
    issue.) The agcncy's ra~ionale this action?
                                   for                                                            S A 0 2 of 95% at 20 minutes of life would see111 to
    Rarr's application did not provide adequate data                                              make lurther obscrvation feasible as long as she re-
    tlemons~ratinglhat Plan R can be safely used                                                  mains alert, cries in response to stimulation, a n d
    by adolescents 16 years or younger wi~hout                                                    maintains good color and tone. Because of the ccln-
                                                                                                  tinued grunting, she will need further evaluation
                                                                                                  with laboratory stuclies, a chest radiograph, and a n
                                                                                                  ECG. She should also receive oxygen a n d intra-
                                                                                                  venous antibiotics. Decisions about additional intcr-
                                                                                                  vention and whether to transfer K. C. to a n NICU
                                                                                                                               of
                                                                                                  depend o n the f i n d i ~ ~ g s the evalt~ationa n d her
                                                                                                  condition over the next few hours.

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                                                                                                     1. Kamvinkel J (ed): Texlbook or N ~ o n a l d Resr~si:ilahor:. Elk Grove, Ill , Arner~can
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                                                                                                  bcadeniy of Pedlatrlcs and Anierican Heait Assoo~aton,2000
                                                                                                 , 2. Hein HA, Ely JW, Lofgren. MA: Neonalal resplratoiy d~stressIn the comrnunjty
                                                                                                  hospital: When lo transpuit, when to kceo. J f a m P n d 1 9 9 8 ; 4 6 . 2 8 4
   ancl cll~c;icy  would hc approved quickly."                                                       3. Siwek d, Go11r13~ I . Slawson OC, et al: How to wrlle an evldence~basedcln,cal
                                                                                                                              M
     Appals to Irwst.rrJc~l~.llo.cblr-cslrictions on$mclin                                        review aitlcle Anr Fanr Physician 2002,65 251
   h>r-stun1 cr.11 rt.sc.n,-cl~nlay he S e t ' ~ ia Inore
                                                  ~~g                                          . , 4. Behrrnnn RE, Kl~egrnanRM. Jerison HH leds). Nelson Textbook of Pedratrirs j.d
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                                                                                                  16). Pl~~laiielph~a. Snunders Company, 2000, pp 49"-503
                lc
   k ~ ~ o n i hrccel~tiou from ~11c  achninistrat~on-                                               5 Zaritsb AL, Nndknrni VM. Hkkey RW, e l al ieds) PALS Provovidsr ,Manual Oyl'ns.
   prrhaps l > c ~ ;nppeals~ ~ coming Iron1 Sonner
                         i ~ ~ are                                                                Arnerlcan Heart Assoc~allon,2002, pp 337-358
                                                                                                                                                                  of
                                                                                                     6 Agrawol V, Dav~dRJ, Harris VJ: Clnssii~cnt~on acute rcspratory d1:orders of all
   Fil-stL ~ d y Nancy Reagan, tclcvision star b.Ii~h~~t.1J.                                      newiborns 1 1a te~llnrycare center JNalI.MedAssoc2003;95(7) 58'1
                                                                                                     7 Kumar A. Bhal BV Cp~demiolo~y resillratory distiei!; n i neo1,iiin~ ln~o.?n.if's-
                                                                                                                                                 of
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                                                                                                     8. W e t y SE, Overvleiv of neonatal rcspralory d~strzs:. Di:ordcrs of trsnston.
   thc prcsidcnt's opposition lnay he weakcning,                                                  iw utdol coni. Retrieved O~tober 0 0 1     2
   Elin, Zcrho~~ni, llircctor of he National
                          MD,                                                                        9 Cieary GM, W'swi;ll TE. lrleconlllrn :tair~cd arnnol~c:ILIII 3nd llle nlzctir!lum ~ r p i -
                                                                                                  fnilon syndrqnie An opdatc fedlsli C1.n North Am 19c10.45 St 1
   Instlhltes ol klenlth, responcletl to the congressional                                                                                       y
                                                                                                  1 0 LIU 'NF, Harrington T. O c I ~ v ~ r m r n 11skIdclors for mll'tonllilo & p ~ r J t ~ o n        sin-
   firoilp \wth a Icller saying thnl "from a purely                                               dronie. ,1,7: JPcriilalu12002,19 367
   scicntiric perspeclive, inore cell lines may wcll                                               I 1 KaWinhei .I.Suliact3nt lavage lor mcconiorn ;l:pirnton. A ,word of ca\il~oniledl-
                                                                                                  otiirs :'00::109       1167
   S P L . ~ L I some are:lsl' of research. As of n~id-May,                                                                                                             s
                                                                                                  12. Ghidin~A: Severe mpconitlm asp~rnlcnsyn~lromr1 1101 caused by nsp,ril~onof
                                                                                                                                  l
                                                                                                  rneconlum. A m J ~ l h s l rGjiiacol?OiiI.lUS 931
                                                                                                                      a                                                                            l
                                                                                                  13. F a l r ~ g l ~ilS. Fa~lureto prevent rncconlll~lla:;pllatlcn syrldronie i l b z f ~ i;ri.,,.ol
                                                                                                  i988;71 319
                                                                                                  14. Gordon E, Sollih M, hlcfloug~~ll et )I Blood aspratlzn ;yridroni? as .I c.:o:L' of
                                                                                                                                              PN,
                                                                                                  respiratory dslress n I I e newborn ~nlanl.JP:'Uialr 2Or:i;l.:: :'n0
                                                                                                  15 Gllnfoor T: lni~denceof rer;oraiory d~slri?nsnyndlnrth.? .bl~!rnai 01 !,he i',':,,:? J                  I
                                                                                                                 2nd                                           5)
                                                                                                  Phys~crarls Surg?snq o l F ~ i i i s l ~ i 1 2 0 0 3 , 1 3 (271
                                                                                                                                                                                 y
                                                                                                  1 6 Rolh K:t:ln?r hl, lyi-igner RP. Exllmann U i.1 nl R e r p ~ ~ . f l r~l~~lr;.?:;       s;r~,I~ixl:?n
                   r!faitdiaatn~viuol i!nifi:i. FDA also
   sorl:hi~ir:fi:~srs                                                                             near-term b a h r s Jller c ~ ~ s - i r c ~ n ccclion Sbv;~: OAt9!c,!i l Y , , ~ , k i y9rj0J,133(1g.
                                                                                                  2U) 2113
                                                                                                  1 I . Tlngestad .I I.lnilr"rpl~a:fl~)1:y31lll~ls     Pdd3lr !trv 1 1P'3,?3 0::
                                                                                                  18. Golnela TL (erl) i.leo~;.r!nlnQy. M.lnnr]r~l~enl, r ~ ~ ~ i ~ l i c.111 r, r .o i i c ~ i ; , C:
                                                                                                                                                                 ~             011 r ~                   ,.
                                                                                                                                             .
                                                                                                  eases and Drugs Sl,~~iilo~rl. I ~ IAiivleinn P L;lrlrJe, lg'j'i, r~21.1
                                                                                                                                     C~       I           .
                                                                                                  19. Rech J D hl~llrr rilogrlol R, 01 .)I, i h c u:~! 01 I)!:? ~ < ~ u i llo /l l c t t r l T l l i : ~ ~ l l l ! ~ I
                                                                                                                             S,                                                    :
                                                                                                  lhonrt dsease. .Ji~3~1r?00111:'13]21jii
                                                                                                  20 Myers TR. ,?nielicnll AssuL~nl~on ~ r ;r%~~rmto:y Cnrc AhfiC C l ! n ~ r a l?r.lctlce
                                                                                                                                                    ,r
                                                                                                  Gu:deine. Selection ot an oiygrn d?llvrry d,'JlLa lllr 11eollatdi And pedatrc p j l e r t s -
                                                                                                  2002 revslorl b llpdste Hrcpir C x a 2007. 1/(6)I U i
                                                                                                                                                o i                       ~v
                                                                                                  21 licndt'rson :moll UJ, V d ~ i k i ~ r A.~iI;lynas i ; ~ i v ~ i oCli. f.ieihancal vcrrllatrn :or
                                                 ]11i/itl1 A s c \ ~ - ( ~ o o i i l ~ i t ~                                                                            o
                                                                                                  newborn infants ,,!II~resplratort I31ltJrpdl13 to p l ~ i ~ ~ !IWr ids:?se (~:ocIlran,! rev^!.)
                                                   C . ~ c ~ t ~ t r i I ~ ~l5liti~r
                                                                             ~lir~,g               Cochmris n.iObose S:sl Rev 1Cfl2, 4 AC007770
                                                                                                  22 G ~ r ~ t I ~ l r ~ eijcjo:I P I ~ ~ I L Ctl1e Ill:lr.iiqsr,cl,t uf ~i.;f~y~ital i p ~ z t o p i~ i ! , ~ : ~
                                                                                                                        lor s               n                                      rr             r ~
                                                                                                  s:ndrolne ilepart of tcu s ~ c o n 4:;ork:nq r j r n p of l i e Hrik:li P',;~;~:hl~on11 P i r n n i ~ l
                                                                                                                                                                      prif 3         l
                                                                                                   i.!~:o,cir~e !vww bapln arg/ilocumerrts/p~~hl~cat~on~/rds~ ' r o v s r J:ini:ary 2,203




7 2 :1)11;1 r?:l'tlRAliY rJiDIArRICS Vul 71 Ilo, ii

				
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