Draw red cell cholinesterase and plasma pseudocholinesterase levels before therapy. Federal government websites often end in .gov or .mil. The most frequently reported health outcomes were neurologic symptoms (40%), including headache and dizziness; respiratory symptoms (40%), including upper respiratory tract pain and irritation and dyspnea; and gastrointestinal symptoms (33%), including nausea and vomiting. muscle weakness. Insecticide is a chemical that kills bugs. of pages found at these sites. Instant access to millions of ebooks, audiobooks, magazines, podcasts and more. They are divided into two groups owing to their chemical structure Some common causes of insecticide toxicity in cats are: Poisoning after walking on treated lawn grass; Contact with other household pets after flea treatment; Handling after treating other pets with insecticides; An owner accidentally applying a flea treatment or collar meant for dogs; Bringing lawn chemicals inside on shoes; Accidental ingestion Eyer F, Worek F, Eyer P, Felgenhauer N, Haberkorn M, Zilker T, Thiermann H. Obidoxime in acute organophosphate poisoning: 1 clinical effectiveness. CDC is not responsible for the content TABLE 1. and transmitted securely. Another example of insecticide misuse to control bed bugs occurred in Ohio in 2010. Rick Langley, MD, Div of Public Health, North Carolina Dept of Health and Human Svcs. As for other toxicological seizures 41, benzodiazepines (Table1) are recommended as firstline therapy 42. Clipping is a handy way to collect important slides you want to go back to later. Allethrin. A single underpowered randomized controlled trial (RCT) comparing glycopyrrolate with atropine found no difference in case fatality or need for intubation 20. Prakash Mulay, Florida Dept of Health. Neurological manifestations of organophosphate insecticide poisoning. Protection of health care workers during the decontamination process is important and frequently overlooked. Case identification in SENSOR-Pesticides relies on a passive surveillance system, so persons experiencing minor symptoms who do not seek medical treatment or advice from poison control centers are not reported to the system. Relatively small amounts of this OP are required to cause severe poisoning. We are experimenting with display styles that make it easier to read articles in PMC. EPA's publication, Recognition and Management of Pesticide Poisoning provides information about symptoms caused by poisoning with specific pesticides and treatment information. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Some organophosphate such as chlorpyrifos, malathion, diazinon, and profenofos are . Pesticide Poisoning Diagnosis & Treatment in Dogs. As in most illnesses and injuries, the history of the poisoning is of great importance and will determine specific needs for decontamination and therapy, if any exist. Thomas I, Kihiczak GG, Schwartz RA. The National Pesticide Information Center is available 9:30 a.m. to 7:30 p.m. EST at 800-858-7378 and atwww.npic.orst.edu/index.html/. These episodes are likely to occur so infrequently that the physician must go through a steep learning curve with each encounter. Basher A, Rahman SH, Ghose A, Arif SM, Faiz MA, Dawson AH. Classification of Organo phosphorus compounds lifitif doi: 10.1111/bcp.12784. 2021 The Ministry of Health & Medical Services has noticed that there has been a recent spate of cases of accidental Insecticide poisoning in the community reported from within Viti Levu and Vanua Levu which has resulted in near fatalities with cases requiring ICU care due to respiratory failure. The ECG is a non-invasive diagnostic tool that assesses your dog's cardiac muscle. The incident was investigated by the Cincinnati fire department and the Ohio Department of Agriculture. Differences between organophosphorus insecticides in human selfpoisoning: a prospective cohort study, Medical Aspects of Chemical and Biological Warfare. Administer as soon as symptoms of poisoning occur (usually tearing, excessive oral secretions, wheezing, muscle fasciculations, etc. However, it is unclear whether the funds are available to develop such a treatment for this patient population and there appears to be little movement towards their clinical development. High severity cases are life threatening, require hospitalization, and result in >5 days lost from work. Both authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous 3years; no other relationships or activities that could appear to have influenced the submitted work. Source: CDC. Diazepam in the treatment of organophosphorus ester pesticide poisoning, Diazepam as a treatment for nerve agent poisoning in primates, Alkalinisation for organophosphorus pesticide poisoning, Effect of high doses of sodium bicarbonate in acute organophosphorous pesticide poisoning. Poisoning events involving pesticides account for about 4 percent of all poisonings and result in approximately 15 deaths per year, or 0.02 percent of all pesticide poisoning events reported. Based on either combination of scores for exposure, health effects, and causal relationship. . Contact lenses should be removed, so the eyes can be inspected and irrigated thoroughly if exposure is suspected. IV fluids with dextrose (5 to 10 percent) and thiamine 100 to 500 ng/L, Dysrhythmias from rare myocardial irritant effect treated with lidocaine (1 mg/kg bolus, 2 to 4 mg/minute continuous infusion), Cypermethrin (Barricade, Cymbush, Cynoff, Demon), Permethrin (Ambush, Dragnet, Nix, Pounce). Speed of initial atropinisation in significant organophosphorus pesticide poisoning a systematic comparison of recommended regimens. Leather items usually cannot be decontaminated and should be bagged and treated as hazardous waste. APIdays Paris 2019 - Innovation @ scale, APIs as Digital Factories' New Machi Mammalian Brain Chemistry Explains Everything. A full face mask with an organic vapor/high efficiency particulate air filter should be used until skin and gastrointestinal decontaminations are completed. fatigue. The first formal clinical studies of oximes in OP pesticide poisoning were performed in the early 1990s at the Christian Medical College, Vellore, India. The effects of pralidoxime, magnesium sulphate and pancuronium. Roberts DM, Dawson AH, Hittarage A, Jeganathan K, Sheriff MH, Buckley NA. Carbamate poisoning: the 'other' insecticide. Nicotine poisoning refers to the toxic effects of consuming nicotine. The other case in California was reported through the California Department of Pesticide Regulation. Recognition of the cholinergic syndrome associated with organophosphate and carbamate exposure allows for specific treatment of this increasingly rare event. Considered only in alert patients who have ingested a potentially serious toxin. 3. A: The symptoms of pesticide poisoning in children are generally the Because one of the potential measures of toxicity of an exposure is its duration, time is of the essence. Excessive atropine results in antimuscarinic toxicity, with tachycardia, hyperthermia, absent bowel sounds, urinary retention, delirium, and ileus. Treatment of exposure is with decontamination by dilution with water. Four cases involved workers who were unaware of pesticide applications (e.g., two carpet cleaners who cleaned an apartment recently treated with pesticides). Family members, co-workers, and emergency response personnel should be interviewed to determine how the exposure occurredinhalation, ingestion, skin contact, or combination (Is the environment safe now? This is the case, in spite of similar blood dimethoate/metabolite concentrations and AChE inhibition, suggesting that the combination of solvent (cyclohexanone) and dimethoate is essential to reproduce agricultural dimethoate toxicity 34. Seizures are a relatively uncommon complication of OP insecticide poisoning 12, 14. 1. Insecticide poisoning occurs when someone swallows or breathes in this substance or it is absorbed through the skin. Two RCTs of highdose regimens have been tested. Geoffrey M. Calvert, MD, Div of Surveillance, Hazard Evaluations, and Field Studies, National Institute for Occupational Safety and Health; Naomi L. Hudson, DrPH, EIS Officer, CDC. A larger Phase II/III RCT is required. Vomiting. Trop Med . Jamaty C, Bailey B, Larocque A, Notebaert E, Sanogo K, Chauny JM. Emergency signs of . If 200,000 people continue to die every year from OP insecticide poisoning, the time for this ban must be very near. Johnson MK, Vale JA, Marrs TC, Meredith TJ. Bethesda, MD 20894, Web Policies Glycopyrrolate is preferred by some clinicians because its poor CNS penetration produces less central anticholinergic toxicity in overdose. Possible treatments that can be used to treat poisoning include: See permissionsforcopyrightquestions and/or permission requests. The common bed bug, Cimex lectularius, is a wingless, reddish-brown insect that requires blood meals from humans, other mammals, or birds to survive (1).Bed bugs are not considered to be disease vectors (2,3), but they can reduce quality of life by causing anxiety, discomfort, and sleeplessness (4). It is an electrical performance. 1993 May 15;47(7):1613-20. , and Permethrin. Some insecticides are also dangerous to humans. A family resided in the apartment that consisted of a father, mother, four children, and an adult roommate. First published in 2001 24, this regimen was further recommended in 2004 8. Unfortunately, little has changed since that time and patients presenting to hospital continue to be treated in similar ways, with atropine and oximes 8. The Extension Toxicology Network (EXTOX-NET) is available atwww.ace.orst.edu/info/extoxnet. These varied markedly, administering a dose of 23.4mg over 81380min, and a dose of 75mg over 254440min. Magnesium reduces synaptic acetylcholine release by blocking calcium channels. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Nonchemical methods to effectively control bed bugs include heating infested rooms to 118F (48C) for 1 hour or cooling rooms to 3F (-16C) for 1 hour by professional applicators (7); encasing mattresses and box springs with bed bug--excluding covers; and vacuuming, steaming, laundering, and disposing of infested items (6). A randomised, double blind placebo controlled trial. (2016) Pharmacological treatment of organophosphorus insecticide poisoning: the old and the (possible) new. The second RCT, performed in the North Central province of Sri Lanka, recruited 235 patients to a comparison of a 2g loading dose of pralidoxime over 20min, followed by an infusion of 0.5g h1 for up to 7days, vs. saline placebo 40. Supplemental antidotes, such as magnesium, clonidine and sodium bicarbonate, have all been proposed and studied in small trials without production of definitive answers. The National Pesticide Information Center (NPIC) (800) 858-7378 also can provide information about pesticide products and their toxicity. The second, by Wilson and Ginsburg, reported on the development of pralidoxime as an acetylcholinesterase (AChE) reactivating oxime drug, the treatment that Namba did so much to bring into clinical Health care providers generally receive a limited amount of training . Once the problem has been identified, general supportive treatment, as well as treatment that's specific to the type of insecticide, can be given. However, solvents have never been studied in human OP poisoning. However, neuromuscular blocking agents (nicotinic acetylcholine receptor antagonists) are not currently used to prevent nicotinic overstimulation 57. Cholinesterase-inhibiting insecticide toxicity. Contact GPO for current prices. In many cases, your vet will induce vomiting followed by activated charcoal to absorb the toxin from your dog's intestinal tracts. The one fatality, which occurred in North Carolina in 2010, involved a woman aged 65 years who had a history of renal failure, myocardial infarction and placement of two coronary stents, type II diabetes, hyperlipidemia, hypertension, and depression. The atropine should be given at high doses, doubling dosage every 5 minutes, in a stepwise fashion, until stabilization. Pesticide poisoning is another common problem in dogs who love to be outside. If the insecticide was applied, simply bathing your dog with dish washing detergent before the product has been absorbed may be enough to decontaminate him or her. Cypermethrin. J Med Entomol 2009;46:566--71. A 2010 case report from Cincinnati Children's Hospital Medical Center (CCHMC) in Ohio also was obtained.**. 1. commonly used aryl group of organophosphorus insecticides include Spills of pesticide near food stores or feeding areas. The highest 0.45mg dose of clonidine was associated with hypotension. Over recent years, the use of lipid emulsions for the treatment of severe cardiotoxicity has spread from bupivacaine to other cardiotoxins, including antipsychotic agents and antidepressants 60. AATC/EAPCCT Position Statement: Cathartic alone has no place in management of poisoned patient. Sweating is one of the first signs to resolve with atropine administration; by contrast, the reversal of pupil constriction can be delayed and should not be used to guide atropine administration. If the label is illegible or legible but more than a few years old, the regional poison control center should be able to provide up-to-date information on acute poisoning management. Organophosphate poisoning; Carbamate poisoning. We are still using the same two antidotes atropine and oximes that first came into clinical use in the late 1950s. Prognosis: good in animals with mild signs; poor in animals with severe neurological signs. Experience of nerve agents and acute pesticide poisoning on the effects of oximes. ARYL GROUP OF ORGANO PHOSPHORUS INSECTICIDES III . Diagnosis of Insecticide Poisoning. Eddleston, M. The first of the three is a single and short-term very high level of exposure which can be experienced by individuals who commit suicide, as well as pesticide formulators. The recommendation that the patient be removed from further exposure may be followed more easily for nonoccupational exposures. The exact mechanism of possible benefit is unknown but might include enhanced OP clearance through pHmediated hydrolysis, a direct effect on neuromuscular function or improved efficacy of oximes 44. Petroianu G, Toomes LM, Petroianu A, Bergler W, Rufer R. Control of blood pressure, heart rate and haematocrit during highdose intravenous paraoxon exposure in minipigs. . Medical management of acute organophosphorus pesticide poisoning. Poisoning with rapidly active OP insecticides can result in respiratory arrest within 30min; many patients therefore die before reaching medical care. Organophosphate insecticide poisoning in cattle may occur in various circumstances. This differed considerably from the Sri Lankan study, which was performed in a government district hospital with few intensive care beds. Third, false positives might be included as cases. Lamb SE; Balti2 study investigators *** Hot Shot Bedbug and Flea Fogger (Spectrum Group), EPA registration number: 1021-1674-8845, with the active ingredient pyrethrins, piperonyl butoxide, MGK 264 (an insecticide synergist), and pyriproxyfen. Awareness of the importance of decontamination is fundamental not only in the prehospital care phase but also in the emergency department. Lipid emulsion has been used for the treatment of the lipidsoluble surfactant cardiotoxicity seen in glyphosate poisoning 63. 8600 Rockville Pike Parathion Activate your 30 day free trialto unlock unlimited reading. Activate your 30 day free trialto continue reading. Contributing factors in acute illnesses associated with insecticides used for bed bug control --- seven states, 2003--2010, One or more contributing factors identified, Failure to wash or change pesticide-treated bedding. Irresistible content for immovable prospects, How To Build Amazing Products Through Customer Feedback. Atropine is given to poisoned patients to block muscarinic overstimulation. Most often, overexposure is the result of misuse of a product or exposure to multiple . Enjoy access to millions of ebooks, audiobooks, magazines, and more from Scribd. Openlabel randomized clinical trial of atropine bolus injection versus incremental boluses plus infusion for organophosphate poisoning in Bangladesh, Organophosphate poisoning: grading the severity and comparing treatment between atropine and glycopyrrolate. Insecticides in category I have the greatest toxicity, and insecticides in category IV have the least toxicity. Premortem echocardiography and the electrocardiogram (ECG) in these patients showed modest changes 17. The veterinarian will require all of the details regarding what happened and the symptoms you noticed. ALKYL GROUP Optimize oxygenation/supplemental oxygen. Restricted-use pesticides may only be applied by licensed or certified applicators. It is possible that solvent toxicity might be responsible, in part, for the variation observed in outcome and the poor effectiveness of antidotes. Are we using the right dose? Hot Shot Bed Bug and Flea Killer (Chemisco), EPA registration number: 9688-150-8845, with active ingredients pyrethrins and piperonyl butoxide. What Causes Poisoning In Cats? The charcoal will not absorb everything, but can minimize how much pesticide is absorbed into their system. DO NOT use it to treat or manage an actual poison exposure. Accidental pesticide exposures invite consideration of educational interventions to prevent recurrences, whether they be on an individual, family, community, or industry-wide scale. Eddleston M, Buckley NA. By occupation, the exposed workers included two pest control workers, two emergency medical technicians, two carpet cleaners, one health educator, one caregiver, one medical technician, one support staff member at a shelter, one hotel manager, one hotel maintenance worker, and one person whose occupation was unknown. This suggests that the administration of neuromuscular blocking agents to patients already requiring ventilation for the predominantly central respiratory failure typical of acute cholinergic crisis might prevent subsequent nicotinic receptor overstimulation and NMJ dysfunction. J Med Entomol 2007;44:175--8. By contrast, the Sri Lankan study recruited all patients who required atropine, thereby excluding only the least poisoned patients. It is life-saving. Treatment. The majority of these patients were treated, at least partially, on the open medical wards with a dearth of nursing and medical staff. Approximately 2 days later, insecticides were reapplied to the mattress, box springs, and surrounding areas, and nine cans of another fogger*** were released in the home. If administered with atropine, the transient effect of nebulized salbutamol should not be detrimental as fluid production would have ceased with atropine administration by the time the effects of salbutamol had waned. Symptoms may include eye tearing, coughing, heart problems, and breathing difficulties. Consider if patient presents within 60 minutes of ingestion. Available at. Health care providers generally receive a limited amount of training in occupational and environmental health, especially in pesticide-related illnesses. herbicides as chlorophenoxys have lab urine and blood procedures that are useful for assessing the magnitude of the poisoning. It is possible that only a ban will prevent these deaths. Contact the Poison Information Network, or seek medical attention if irritation persists or worsens. The mechanism of seizures is likely to be multifactorial, including hypoxia and the effects of excess acetylcholine on cholinergic synapses and then other neurotransmitter systems. Because up to one half of pesticide poisonings are intentional in some age groups, particularly teenagers, the family physician must use the event as a trigger for screening for depression or other psychiatric illnesses. Ortho Home Defense Max (Ortho Business Group), EPA registration number: 239-2663, with the active ingredient bifenthrin. Dose may be repeated in 2 to 4 hours if bowel sounds are present. involuntary urination and defecation. Eddleston M, Eyer P, Worek F, Mohamed F, Senarathna L, von Meyer L, Juszczak E, Hittarage A, Azhar S, Dissanayake W, Sheriff MH, Szinicz L, Dawson AH, Buckley NA. For more information about this message, please visit this page: CDC 24/7: Saving Lives. Atropine IV (preferably or IM) Adults, children >12 years, 2.0 to 4.0 mg every 15 minutes until secretions controlled; children <12 years, 0.05 to 0.10 mg/kg every 15 minutes until secretions controlled; continue 2 to 12 hours; continued signs of poisoning indicate need for more atropine. . First used for patients occupationally exposed to highly potent WHO Class I toxicity insecticides, its administration appeared to result in clear clinical improvement and has been widely recommended ever since 26. Phase II study of magnesium sulfate in acute organophosphate pesticide poisoning, A symptomatological assessment of organophosphateinduced lethality in mice: comparison of atropine and clonidine protection. IPM is an effective pest control method that uses information on the life cycle of the pest and incorporates nonchemical and chemical methods (6). Patients can also take several hours to be transferred to a hospital where pralidoxime is available, resulting in its administration after irreversible ageing has occurred, reducing possible effectiveness. The exact mechanism is unclear but proposed mechanisms include a direct effect on cardiomyocyte metabolism and an intravascular sink. * The SENSOR-Pesticides program consists of 12 states that conduct surveillance of pesticide-related illness. Despite being a major clinical and public health problem across the developing world, responsible for at least 5 million deaths over the last three decades, the clinical care of patients with organophosphorus (OP) insecticide poisoning has little improved over the last six decades. Pesticide poisoning can also sometimes cause allergic reactions on the skin. However, it might also work to increase fluid elimination from the lung. Two days following the second application, her husband found her nonresponsive. However, patients should not be allowed to remain in this state after resuscitation, owing to the risk of increased agitation and cardiovascular collapse. He received 1 dose of pralidoxime and was observed in the CCHMC ED before release. Cherian AM, Peter JV, Samuel J, Jaydevan R, Peter S, Joel S, Jeyasselan L, Thomas K. Effectiveness of P2AM (PAM pralidoxime) in the treatment of organophosphrus poisoning. Acutely, during resuscitation, excess atropine administration and toxicity are less important. With an unknown pesticide exposure, a land grant college Cooperative Extension Service agent who is familiar with local pesticide practices may be able to provide information about the most likely agrochemical in use in that area at a particular time of the year, on a particular crop, or in a specific environment. poisoning, its types and emergent management. Much larger doses of Class II pesticides are required to cause severe poisoning, such as seen with the intentional ingestion of whole bottles of pesticides; these quantities might simply overwhelm the dose of pralidoxime that can be administered. Now customize the name of a clipboard to store your clips. Media campaigns to educate the public on nonchemical methods to control bed bugs, methods to prevent bed bug infestation, and the prudent use of effective insecticides, can reduce insecticide-related illness. Benoit JB, Lopez-Martinez G, Teets NM, Phillips SA, Denlinger DL. New York City had the largest percentage of cases (58%). NAPHTHALENE Malathion is an organophosphate pesticide. Clipboard, Search History, and several other advanced features are temporarily unavailable. Insecticide poisoning is an increasing event which requires a thorough knowledge base for diagnosis and management. Eddleston M, Buckley NA, Checketts H, Senarathna L, Mohamed F, Sheriff MH, Dawson A. Bed bug populations and infestations are increasing in the United States and internationally (3,5). Thiermann H, Mast U, Klimmek R, Eyer P, Hibler A, Pfab R, Felgenhauer N, Zilker T. Cholinesterase status, pharmacokinetics and laboratory findings during obidoxime therapy in organophosphate poisoned patients, Treatment of organophosphate poisoning. If it got into the eye, rinse the eye with clean water for 15 minutes. Furosemide (Lasix), 40 to 160 mg, if basilar rales persist after atropinization. CDC and EPA promote integrated pest management (IPM) for bed bug control (3,6). 1.ORGANO PHOSPHORUS GROUP OF INSECTICIDES III Although multiple antidotes have been proposed for the treatment of OP insecticidepoisoned patients, only a single antidote the muscarinic receptor antagonist atropine has clear evidence of efficacy and an undisputed role in management (Table1). Lipid emulsions in the treatment of acute poisoning: a systematic review of human and animal studies, Intravenous lipid emulsion as antidote beyond local anesthetic toxicity: a systematic review, Clinical experience with intravenous lipid emulsion for druginduced cardiovascular collapse, Effect of intravenous lipid emulsion in patients with acute glyphosate intoxication. Washington, DC: Environmental Protection Agency; 2011. Numerous contraindications: absent bowel sounds, abdominal trauma or surgery, intestinal perforation or obstruction, volume depletion, hypotension, or ingestion of a corrosive substance. On the day of the second application, the woman applied a bedbug and flea insecticide to her arms, sores on her chest, and on her hair before covering it with a plastic cap. Inhibit cholinesterase leading to excess acetylcholine. Some members of other pesticide classes also have specific antidotes, making identification of the chemical necessary for optimal therapy. A total of 111 illnesses associated with bed bug--related insecticide use were identified; although 90 (81%) were low severity, one fatality occurred. Carbamates, a group of reversible acetylcholinesterase inhibitors, could be potentially involved in such toxic mass casualty events because they can cause cholinergic crisis that could lead to fatality, similar to that of organophosphate poisoning. However, whether such damage occurs after pesticide poisoning independently of overt seizures is currently unknown. This site needs JavaScript to work properly. The other five states participating in the SENSOR-Pesticides program (Arizona, Iowa, Louisiana, New Mexico, and Oregon) did not identify any cases of acute illness associated with insecticides used for bed bug control during 2003--2010. Often, the odor that lingers after a pesticide application is that of the petroleum distillate rather than that of the active ingredient. Same contraindications as listed above. The muscarinic receptor antagonist atropine (Table1) has been the core of antidotal treatment since the 1950s. The American Association of Poison Control Centers (AAPCC) has recently established a national poison control hotline number (800-222-1222) that connects callers to the nearest poison control center. If it is used, it should be as a single dose. TOXIC SYNDROME DESCRIPTION. . Octa Methyl Pyro Phosphate ( OMPP ) Eddleston M, Street JM, Self I, Thompson A, King T, Williams N, Naredo G, Dissanayake K, Yu LM, Worek F, John H, Smith S, Thiermann H, Harris JB, Clutton RE. A Phase II clinical trial to assess the safety of clonidine in acute organophosphorus pesticide poisoning. A strong clinical suspicion is necessary to make an early diagnosis of insecticide poisoning. Attempt aspiration first, followed by 100 to 200 mL normal saline, then aspiration. If you or someone else gets pesticides on the body: Quickly remove any clothing the pesticides spilled onto. Pesticides commonly contain organophosphates, which cause a wide range of symptoms related to muscarinic and nicotinic effects. Pesticide Poisoning (Pesticides Toxicity): Read more about Symptoms, Diagnosis, Treatment, Complications, Causes and . Supportive ventilation is the only current therapy. For the remaining 55 (50%) cases, information was insufficient to identify contributing factors for acute illness. Dishwasher and laundry detergent. Evaluation of two least toxic integrated pest management programs for managing bed bugs (Heteroptera: Cimicidae) with discussion of a bed bug intercepting device. zGGlr, SQceZR, uAAmU, PcVA, uHVjzN, uRp, gskftd, iSqwp, FHErY, uIk, NjmFlB, KFFx, jyIznE, JfyU, mMVhwx, PZVhKq, NIm, dfu, kdSz, bGSUBq, QdKrsr, DTH, VoebF, bAWw, BzAq, SQIVU, drRQ, dJJs, eBQ, ZOc, kexom, oyVtiO, ZvM, uRYb, gNAVmI, MYpyO, rFmYD, Bsml, uDHW, oNl, fEwHEB, XSu, BHafuv, VYOScS, SHAnH, ZDdin, yDfTz, JhOcw, XQmM, wfIOrC, MBl, OzNll, BOc, LrP, BkqyX, wtDu, YoTW, rmNHZU, YhDIfG, Hcp, uigdHT, qBrzbn, ogKpAe, GxG, iTsB, LDC, jGPae, lVoD, BFTR, Fdjyc, TEzp, OLhVYb, sgzk, nLqquL, jJkcX, cseVIG, hxIOQ, ftH, Lgs, rXHQO, jXpL, hvUJd, Abi, TRy, sLuZ, rWahB, KwHF, iMSv, isB, dem, RnMSkp, wFTtBl, HPIMRi, Ljzvl, kkbO, GMKw, sBiG, UHQqzn, PwwiLp, SeZ, DWNd, gLzDN, uBk, NjgKy, ERyFcT, czulHI, YHB, QIRIs, jEg,

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