Australian paediatric hyperbaric uaygen therapy 1998-2011 6. navi abner see AN sie es ct te ts a ane Bes St ‘Hyperbaric Meticing, Fremantle Hospi, Peth, Westers Australia, Australi - SUMMARY Fora large numberof ichaemi festive, lammaton or raumat conditions, hypebusiomgen ther {ihr te only Weatinent or am aac hat signify reduces morbidity and mortal. The primary i of {hs revie sto Meni ial codons rested nn padi popuaton reece to Australian bypecbaric lite Secondary aims ave to desce utcomes of Weatient and etal ny compliatons ocueng ring testment or daring transfer between vit “This wus a eonpecve cohort sud aay 1998-Desember 2011 of iren seated at four Australi ypotars mest unis, A tot of 112 cilren underset 1089 byperbai teatment for 18 ination. ‘Ages were not normaly distbuted witha medi age of Te yeas (interquartile ange 1-16, range 0.25-16 sears) Teatment were completed as pled in 81.5% of cases with 23 patents treatment terminated at The request of pins, pent patents, Completions ‘lating to ypesbare oxygen ther oacuted in sb reaents (599), Cental wes stem oxygen taney occurred in 1:36 reaments. Ou figs inate that peonsion of hyperbate angen therapy te children ese in major regional hypebare units fin isasoited wth ow compotion rites. Management of eile nan alt hyperbare ality, howewer, Toutes gnc cooperation be wee pueda inenve care and hypebarc conan she need for {rnsfrtoamotier hop and praongedtanporsaten impact x optinal ongoing sia and intense ‘are management Key Won: pease ompenmion, i Hyperbaric yen therapy (BOT) ithe prinsy eda remem fr decompresionsihness and titra ga embolism and ao am adjunct reat tient for necotng sf se intstion, esti Injoneecss (gis pangrene),erotsing fact ewe toumtie incom eben dibetc and Ion-abetlIypoxie problem wounds, chronic Felraconyexteonyes, poplin for prevention fof osteortdionecoss, radiation sue damage, com promi skin gate nd some pes of inacania Miscentex. The: Undersea and Hrpebarie Medial Society defies HBOT as "a teament in which int breathes 10% oxygen wien areatment tert epleng He am mc ny Cot tt ie, ‘apt pin ee enn cre nt, eda, campos een oncom amber at» pressure higher han sea eve pressure (Gs. >1 nimopere absolute [ATAD", Hyperbaric ‘hauber are pil operated at presues abore 2EATA for pers of 60-10 minutes pe eatment Session, Such doves of omgun have © number of Tene) boshemcl, eau and) plysologe secs Preintsle patients are treated neque at Iyproaic asin Avra due (0 4 aumber of faeor, Fist, Asli Typerbrie medial us ‘ne Toate in adult hospitals and eaten of hi ‘kon often requis intros transfer. Secon, tere ae very few puedatic constants wit ppuopriste hyperbaric experience and thd there fre ow poblihed sei onologit nd etre ieshstsinbalaneing the ike oftasfering eal clé wih the {oui af Iyperbare nye thea. In aon, thot isa pteption thet nperarc ese therapy Fr ssocited wih sinicant rik of barotrauma r= lated side-effects, This may also ave lined the iia tert of cidren for treatment, "The primary aim of ths eviews eat iia condone tested a padi paat refered toPaBDIATRIC HYPEREARIC OXYGEN nda, pp lm of an pring con pbc a ‘ma angen . cutiy arc 1 Aone toe Nera at » Ned et jt uke a adn ety ‘an omens 3 entey 1 seer 1 Cire sone yea : 5c) e760) Ge, ame 5) may a) mea 6 nays 209 aay us 20 may sa, ns69 say nian 6s aay rr 66) m6) 2a nao 2s) nsan 2s 60) way oa aan say 8 a0) naa me 2409) Cn eT) oy a 30 “@ at eat 10 maw teawn Australian hyperbaric units, Secondary sims ate 10 Aereribe outer of tetaent aad To detorane whieh complains ae specify relied to teat tment of chien ind hyperbaric unl. ad ‘nck stem cansequeae of her wader ia "There ave 5 hyperbarfstesin Australia: ighe in major puble hospitals ve in private acs and to ili Teles. Mos patents, and pec rally patents, are teed in mult lice reompression ches witha inte number ‘of tresments beng atid ov in single occupant (mong place) hyperbaric gen chanbes. METHODS Approvals fom four bop? human ties research commites mere ctsined (Alfred HREC 37208, Prince of les Hospital HREC 10/75, Wesley Hospial HREC 2012-07-46 and Fremantle FIREC 10190), Following approvals retraspectie sinly of consecutive patients aged 16 and under, wate in strain hyperbaric nis rom uly 1998 end y searching the tase of partesting Inypebare aslies sing age at presentation as eter for inci Data collected incaded emographic deals, enc inieatons for HBOT, ypetare treat tales od ee compton fring iter weatnent or tar. Mising Incomplete data were obained fiom ease notes an Hospal pathology databases. A rovew of ich patents notes was undertaken to deteralne Sic charstrstic ste of Infection, caste Dthogens emorbaies elaell management and% GG. Prawry, M, BENwErr Er aL ‘outcome not resrded! on the hypebace database precipiating events dase seer, ancy therapy wed and compiatins Tiny oweomes recorded were ural wit coplet relation (of the condton, survival with tin mobi, (epestd debridement oF graf suv ith major mobi (major debremet Or amputation), eats sad. yperbaricrelated amplicon. A review specif dia exrction form was sed 3 that the same data way extracted fr eat patent a $0 -mbsing data were clear apparent. These data were {hen exported tan Excel opens fr compaion and ana Continuous data were describe as either ean (standacddeviatien) or median (nrguntl range) Hf not noemally stibted. Deserptie statin lone ate presented. All anaiac were petformed ‘ing the stated package STATA (Coleg Station “Tes, USA). RESULTS Four hyperbricuns provided dats onthe children ‘hey treated. Thee eter hypebaris nts ndeted they had not tested cen in he timeframe of thi sty, andthe ve priate and th mary units Indicated they had never vested eilten. From 1998-2011, 112 chen aed 16 years of age and under weve tated with HBOT for range ‘of condtions (able 1). The medn age was I yeas (otergurite range I-16, range 025-16 yun). ‘rentmont tables sed were eal to thse sed in. an adult population with the sme condition, Decompression ess and cerebral arterial gas embolism were treated with 2 Ray Nay table 62 Which imvotes treatment ats maximum presie of 2.8 ATA forfour houte snd 45 rates, Fllow-op treatment as witha Royal Ney ble (28 ATA for Iwo hoars and 15 minutes). Cesta myonecrosis inal treated with a3 ATA tlle fortwo hours Sid 11 minster one patient aad «28 ATA table in three other paients. Acute nce fit, ash injory ad comptes ayadone. alin rp funn, were ested Wiha 28 ATA table forone hour and 35 mines Racers ced ‘oft tue injury, osteoradosecos, esteomyetitia and comple regional pa syome wee sl ented ‘One patient with cxgephals reseed eagle 28 ATA treatment using he (020 HOO) for one our and 35 inate. “The 2 patents recived atotl of 1099 eaten sessions (teas 93, sandar! deiion 11, 95% confidence inter 73-113).Inthiseres paints (lov) socessly competed (eaten, al 19 Patients having treatneatstexlnated prematurely by patients, pens or relerring einen OF the ic pitts howe tentments re terminated by Fetering clin, fe were ceased beer the lini ‘decided that fypertaie weatment was lnpouing eda! and surgi! management. One cl ith opie newropaty demonstrated siden Sctesraion in eight flowing third treatment fad HBOT was ceased bythe ophthalmologist Of the four paicntgenerated early cesaton of teeament vo chien beeame seat nell ould not complete HBOT, one cd with muxclar “Satropyaid not tolerate therapy de to respiratory ‘Simpomise and one was ceed due fo aggresine Piet behsour dering treater, Seen pains Wee fom teetmenthecsse of inestng niet and austrophobia daring teatmen. Foe tints parent requested termination of eatin, “Thien ren Vere rested wile sil ein etltion suppor. Eight were refered fom ordi ntensive care unit ad Sve fom an aul Insite cae unit. Davi the period 1998-201, 4 ‘oul of 1,284 patients recived 3,445 treatments in “Astalian hyperbaric uns Chileon 16 year 86 tin under therefore represented DAU of pants treated and 036% of all ueatments, Inicio Tndeatins for treatment were clase nto eiht bod extapovies (bubble injury’), cate ater ‘Schaemi, acute severe infection, mheling ound cisbon monoxide (CO) poisoning, edition Induced sft tissue lnjas, eefractony stones tnd miscellaneous Table) Thi sheen (Go4%) were tested fr acte chemin (27.78 ‘oF tot treatnen). This ined 1 sompartment Sydromes, 16 ru injures, fou chee gen ‘aps, ene doghteindaced femoral artery sac, fone sever frostbite and one atrial ehaenia Secon to aogens sco ineston during an Intrventonal adiionyprocdr, ‘There were 20 ener of nite svee infection Including Yen oecotsing sof tise infestons, four clostridial infections, three meningocost purprs Tuminans and thee ssteniefrgal inetons. This represents 173% ofpallents and 18 45 of teat. ‘en paediatric pants were ies for neerotising fastits. There were setea patents th pe 1 (oiynirobil neerotsing festa three patients ‘ik ype 2(monomierabil or group stopococa) recothing fscits, Precipitating. events inloed ‘cue mphogytc leukaemia with aetrpenia (urPaBDIsTRIc H¥FERAARIC OxYOEN 7 case) acute myeloid leukacmia (one cae, spider bitte cases) andtauma (tre cise), The fene nani was Pseudomonas enginoea in i ees, [youp A bots haerobtsreptcoces i tre ces {nd Sapyfcoceus aureus wit ox shck sora income case Four patients were tented fr ctl infection inluingclasuet myonecross of the toma wall lida snoneron ofthe high ‘nd gta! muses, lost cellitof the knee {nd enteroclisnecrotans othe jejunum (igh. Organisms boat were Condon pgs po ‘A ovo) Clas sewn (ae) ana Coun ‘ofingers spe C.Ivaive fungal epi cere in thee patent iovoling the jem, ng abd ori, “The causative agent was Mucor indus ggompeode {one inaabamial mor, one thao and ‘ne aspera zou pun “Tes patients with severe meingocosal ease With significant peripheral arterial compromise (purpurstulminan) were tassfeved for restment, ‘The causative ovganan was Nesuor megs setup B (mo pains) and ype C (one pati. Tbble injury was the indeston in 1.6% of patients and 889 of treatments Inloded fn this |roup were nine teenagers ete for Scorpion Ines and four patents ete for cert stra a8 emboli. Cerebral ars gar embolant fccrredduveg eine sirgery in v0 palin, Owconaf po ye sey incon ~ ry ‘aaa Cinpreet one 5 , 2 coma wos oa 1 are p68 4 oe fn opening ys Myce ee oa ete iy 1 Opting 1 1 Greil palstone 1 ovens ot Re! i _o1989) wou) 968) 095) ‘Me a pl rag ela ln, a Se ae sn Mie ni sted earn ara ping Bu Pe ne ‘Sedona ite can aed scope nn sees Pt ss hues pears ey Ones eneA GG. Praoitey, M. BeNETT ETAL ‘ne tl following sub dig. ao ove Tree fins were tested for otenpetis olin the {Eur phtease) pli (one ca) foot one cs), mens one ese) sod mangle (One exe). Eleven flats ere ated for eon ra-eling wounds Tetlowingfaure of conventonalwrpcal approaches fin! mllpronged sbi they. This included ‘it surieal ound wo patents mth biopsy proven ‘Mbcobrerern coon Bees) and tree Dientsth seer periaal fistulas Cok’ dee ‘Nine cleo, were treated ar CO polsoning fncuting for member ofthe sane uy who were ‘eure fom a bogged four wet die vehicle. All ‘ere teatedwith10seonypenattescene and hadno (rer newolop deft after HBOT treatment. Fost atents (148 of patents and 20456 of treatment) re ucned for saltion sit tse injury (0 Around breakdowns, one veseginal fistula and Une blaer pecorton. Two potent wee treated {propor oteradinnecesis ofthe mandble ‘nto patients fr avselar poss ofthe ems tr tin senda to desaethone chemotherapy ‘or rete meld eae, Tour mielaneaus indcalos were reported, ‘one patient with Lebers opt nearopatly and ‘Seroatng ison developed neuen deeroraton ineyesiht follwing the third texment Hypesbace treatment was cssed. anda review bythe tphthalmologst nvoied at a Cree month check: Up demonstrated no farther detoraton or sight ‘oat improvement. Oe patent with exeral aly {eented 20 HBO treatments wiht any objective Improvement in nouoderelopmenta state. One fae with, compler repel pn yedrome {Comply regina pin sao ope) olin thetet eg underven 33 eaters following fare ff amteptine, gabapentin, ezaalin arbor peau blocs auavenous guactidine Bock and ESiavowralmodietion techigues. One infant dovelope ageepls after a nl osypen caster ‘iced ater reer from cogeital craic srgery {fas found to have trvesed the eibriorm plate tnd deposited a Lrge oxygen bbe in the anterior ‘cri oss, comes ‘Outcomes of hyperbaric weament are detailed in Tbe Compre fm socovery occured In 67 694%) eaves Minor distil secondary 10 Finitomg, exehovotany, mina amputation of skin irafingoscured In 34 004%) cates. Major ds Fy “including perssent-eurolopainjry, Imior debridement of major sputation occured Inine (8) eases. Major and enor day wa ousidered to hve oscerzed a res ofthe under jing dase procs or sural procedures neces) (ent te propession of injury. Tere were no ‘hatin ving fypabere treatment, Dut one child {fet of completions of fangs! patrons pio 10 ‘sompletion of hyperbar tery. openers Topebarc sideeffote were dained as those events spectelyclaed 10 ineresed atmospheric pressure andor oxygen concentrations, There were Be aere eset in 039 ueatmens (530), Adverse ents oeting ding HBOT therapy ead four ‘Teed grade’ Lor I mide car Breau (045%), 2 eps of amsety (20%) thee ase foxy oman (09%), tee pulmonary oxygen tox ‘roms (0%) 18 elder of ausea (16%) thee Epes of progessne fyporacnia (035), four pods of bik Iypotersan (04%) and one ep Eo of smplomatc ypogjenmia. No hyper Aldeeffente causes ongoing moriity or dati Propiyacte myregotomis were prfoaed in 13 patents (1.6%) poe oreatment. “Ther omgensndaced conulsions ocurred (an incidence of 1366 tentmens). The fist oscured in patient ith aecrfiing asciso the high daring {he thie HOT teament at 28 ATA. The second fncrred ding the second treatment at 24 ATA in lint wth ehonie non-healing fal wound ‘xeriag Tange terorenoes malformation. The thi occured during the fs eament at 24 ATA ing U¢yearol boy wih lover Lmbersh iauy DISCUSSION "The mast common indctions for. paditic hyperturic omen in. Asstraian hyperbaric unis see acute tral ashen eaves al, ete ‘Gvere infection, CO poss, chronic wounds and Chron estennyelte These indications ae conte {ent with lndetions appeoved by the Hyperar ‘Oxygen Therapy Commitee of the Undersea and Hopertarie Media Soceg, The. Undersea and Hperbarie Medea Socety approved tse of hyper bale omen tery In decompression Hs, or fs emotional moss and myoncros, ecoting sft ue infetins, CO. poisoning roth ajey, comparinent syne and chet ‘Shut tune Aeon, areal ici, Entaacement of align selected poem wounds, nmpromied.gnfte and. Maps, severe anaemia cranial bse, refracon exons dled dition soft tse jury ad vce thea bora Injury, Thre emo Fandomised contol as in eden of hypertsieoygen supporting any ofPAEDIATRIC HYPERBARIC OXYGEN a the sve contin; however referral for tretnent was based on physiol principles t ‘count eidenes from tl ale Thecotions eaten ths series are significantly sseren wo thse dosed into other series of ‘ron refered er hpperbare omen therapy. Wasa ‘ta reported on 139 puede pains aged wo months 018 years of whom 79% were treated for ete CO poisoning and 92% for traumatic sca: Inia. Keen ea reprted a ease series of 32 il ten aged Retyen three ay and 1 yeas of whom (ost were treated Tor necting iafectons, 28% for CO poisoniag and 65 fr atogenic ater sie emt "ypobase oxygen therapy bas an inpertant sole ln the managument of este severe infections ‘special dosvidal ayonecosis and_ nerotsing fabs The primary mecunisns of Iypebare ‘gen in acute Severe nets inl restoration fof nomena of achiovement of Ayperais in previously Typos tisues._aiition of exotoxin Production, enhancement cf neutrophil function fn! serge enbancement of abiotic activ ‘Necotsing fasts is aren cildbood andi oon caused by group Abela Inemolytc steprococc but ako by ote aerobic a anuerobic bacteria Ineuding costa pseudononsy. Buetotis fu ils. Stptoocens suns, Enerobactr oacae Sd Kieiale preimonine. Secs treats! of ecrotng fascist hyperbaric nye ineiren Insbeen reported in fsr sl seres™. Jobo e al reported seven ens of necting Ets ith Imyonceros in neatopene paediatie oneolony Diets and demonstrated syneastc effect of Spal deeidement, HBOT and ranalogt colony malting factor, Golger an Brogan reported tow ‘moval vats in children wi group A streptooocal secrotising ass secondary to varcela!. For lost mgosts and rayon (as gngree) fr spreading losedal cells Wh stem toxily the prefered testnent is conbuaton St hyparseooyen, suey aod antbotie A 2e'S'ATA typerberis ongee produces tissue pO, ‘aes of 250-200 mig These tse values are ‘cero to ele and aio impedes toxin production. Three cine presentations ofelostdal seas (dosti nyoneerrs, loses fand enteroealisnecotans) vere demonstrated in ‘ur serie™. The Incidence of Clos perigee fs gangrene in clden Ic Australia and) New Zealand is unknown but presned tobe are. In a ten year period (1971-191), Unsworth reported 73 patients (225 mortal) with a pngrene of which 17 cases were tha 19 years ag, with 0 ess ‘han two yeas of ae. Hyperbaric oxygen therapy has been eepated a effective in eating sil infection oe gus gengrene in pace eae reports ater penetatag nary tothe hes ad neck (nee ‘aes and spomtanzous lst nyonectois thee eases)" Spemtaneos clot) myonecros. ‘sully associated with Ces spic infecton and fen has @ markedly fulminant nature despite Inteventiondueoitsascciation ith snalignoneyend Immusalogeal abnormalities. Entriipecotcans (abel) is caused by the bea toxin produced by Clourion pesfingens ype C. san often atl lines chartered by amoral natty or iehaemic nero the jejunum, Purpore flminens is 2 Me-threstning dasue ot chikrencbaractesed by progessnepurpre lesions ofthe skin, primary om the lower li, that eventually become necro Acute acho fen occurs a result of disseminated nan ‘oagulition or scondaty to compartment syadomes. Hoperbarc oxygen may be of Benet in purpra Fulminans dung the phase of acite hehaemia, uring reperfusion ana” daring the hesting pms, ‘The tse of HBOT for puede purpura fais hasbeen reported in even case reports wih a (0123 patente. In thee cae report, nb sage as pose in 21 ofthe 23 patents In this sve, Iypeborc onygen was wsed in 34 eases of ace peripheral areal schema. The use of hypertie ‘yen in compartment syadrones and erashnuies is siported by a name of elnil oes ad one randomised concolled wal. The mechan of benefit in cute compatnent syndrome itveft First, HBOT hasan ost eet to rece se oedema. Second, HOT inhibits neutophl beta: 2 intgin funtion and modifies endothe dye function ischaemia cepertisionijury. Tht, 'HBOT luencer wourthestngytabitsing growth fectos, prot factor receptor an endl sem cells fom the bone marzow ria induetion of etic ‘pperbarccxygenisrecammended for aciteseite CO poisoning tall bat ene Asean Fyperbaie nit Hyperbaric ongen may rove ovteae by redoing the binding of CO to haemesldin, ‘thing pathological endothe eukorte a sion, inhbing iid perosidation, impeoving mitechondvial xidatve proces, reducing bein reperfusion injury and preventing intacranal hyper tenson, The bale of earbohaemalebin ie Feduced under hyperbarte conditions (249 minutes ‘westhing rat | ATA, 7 misuts breathing onaenATA snd 2 minute s125 ATA a 005 omen Despite seer randomised comtlled tak and ‘systema review of pblhed papers the ue ‘emai contentions. The Allied Hypetatie Units ‘he only unit wich reeomaeads normobare cnygen rather than hyperbaric onygen to rest patients ih CO poitoning and has never treved childhood CO. otnng wih HBOT. ‘The we of HBOT for paca perianal Cos sexe tas not_presiosty been reported, The pathogeness of Cots dicate thot to be enti suscepibiiytiggered by envionment factors. An exes inflamnatory response iva Wing actated immune cells resin perstent fnfmmation and sue Injury Hypetbate omgen therapy my onto infection, ror sue hype dovieregulte infunsnation an! promot tissue ropa “ho clten were diagnosed wih Mycobacterium teens skin ulcer This ond’ various know 2 Bairnsdale ler, Dsintee ler or Burl ler Andis det abortion of ip ex mycolstone, hich cases necrosis of fata thetancous ‘There his only been one ether report of the wse of Iypesbatic agen to teat Acoma wound, ‘A numer of uscommon ndstos were treated in this sere inluing comple eioal pain syndrome and execphales.“Testment se based on lel consensus and «psiloc at for action atmo ‘andamisd controled ial exis o support the se ‘oC HBOT in peat Kia et reported ened in adults wth complex regional pain sjadrome. in oxble- bind randomised, plceho-cont ald study ‘The use of hyperbri hsion to tent a osypen ‘or air preumocepbalvs ws base onthe eet hyperbaric pressire on counterdifsion of net ses, Hydeguard et n* dese a move rapid ‘esoton of injected alt bubbles at pial white ‘tter wit a hetios (820) mise than wt 10 ooygen. Outcomes ond compiions Outcomes from eur svies ar not retiy com- parble to wo other psec cae seis”, Both hese sets were daa om sient em (1580~ 1997) and had dillerent case mk. la sete by Waisman otal, 79% of ehlden tiated had CO, owoning Tn contrast, Keenan tly series costed inl of patients tess than 12 exe of age with ecrothing soft tse infection (36%) and CO. okoning (28%). Waisman eta were ten ‘under 18 years age and eprted complete econery G. Paaviy, M, BENNETY Br at ns with vo eats (1455) an morbidity in 7.496 (npuation in sx patents pitt nextaogin Injury in thee patients aeons, Keenan et al reported that 43% of patients were comidered ‘ocala cara, 375% had mor morbidity es res ofthe a entment and moral wos 12590. Me repoted motalty rte for poodle ‘meningooscl sepsis purpura anions 238 for necrotsng scsi 25% and cst) |asangrene" 25% In our sere by conta there ‘were o dats the 7 ein ith het esses “The overall rte of compton fa thi series (5.39%) slow, with most completion being minor ‘nd selling. The inidene af aypen induced seins (1366 teamens or 0:6) in ovr seis I ositent withthe osdence seported in the two edit serie ba higher tan the iedence of ental neous stem txt inal. The ental nervous syste tx Inedene in ads rented the Fremantle hyperbsi ei ding the sme tine {exe was 1681 eaten (0.06%), with higher finckence at higher treatment pressures (1339 af 28 ATA) and in patente tated for decanpreson nes (1:78 00865) andCO poisoning” Waisman al reported two epodes of oxygen foxy: one pulmonary and one central nervous stem In Keenan et a's sees there wore 47 complications ‘or exes occuring ding HBO therapy ncading hypotension (629), troncbspasn (345), hem ‘gmpanu 13%) ad progressive hyporacti (6%). ‘CONCLUSIONS In selected eonions, HBOT for cide is 0 sife and effective therapeu option. Complications ‘elated to hyperbaric omgen therapy ae largely re Ine to te unecging sense pres with Boo. trauma se effes boing ancommon. Management of children in an sda hyperbaric. however, equies anfiean co-operation between padi Imensve care and hyperbaric constant Ihe need for waster to spots hog and prolonged Iansports fen impact on epial ongaty sug and infersve cae management. The lack well esiged andonised conte paediatesnies fan impediment our ably to quantify the Benet of hyperbaricengen in act sovere ifetons ee shoul ean area rte investigation. ACKNOWLEDGEMENTS ‘We nou to seknowedge the asianc of Sue ‘Thurson, Sharon Pou and Jot Fares in database searching and colton of pation information,PanDIATaIc H¥PERBARIC OXYOEN erenmers “cota so re ec SUMS Rereces emes EIB ma cw ‘it ae: ne Samos TEP mac ie Ecsta tc a Sire Ste ae ce See cecal craters mramantee tenia ES ince aac ine ‘ncn is eat Aa te rh Seen aaa tnd opt ae ei ne Co ed 1 fe ero 0 th rhe Summers satiate at nia hentai Sreeeesta AE 2 nan cen Seite ion aoe 2 Rie erm Schaiter “ft oct Ra 1 ote a Re Wi Tha ‘ i sing fet then oe aa ‘cut ipa cy ES Eto ot hey nate eg tenes Cc 1 Bor Capt ate CN Rec ‘evened hats Poe ‘7 Uso it a Lge een hematin eo Md a A ft ac tpt 18 en Merino ie AL pete en ny ax op ee ero i. a 2K rd Ke, me safe AraC ncn no Pee cer mune oe Onis a Rater edie en aman Seine nrtarneaocnd 25, Daeg Num Z, lr A, Enh D, Gla a Rimage hese, coat See ee nat Ree a kzjtiarminmne cease toe ee or BROTRGRR ees edeca m eowepatope Satie de i a ye rt ey LE reteset Saeco ‘Senge taken seas mee oS cance ore ES conan eco Sone a Sec ea ii ie et ara ou SEEING SRE A et rae a oa a a ‘pense ping ested wa ype Ogun ty, ‘XP a8 Se fee sagan Her Ee Asetin fcn ‘cn mn Nis po eee 2% Mert tS in, hn tonnage livtewpesrmagirs ere Che 3 1 fi Ri a Bee i as {ect aaa eee Sette Newel ee se * iteatooaiese sansa Chea {Kop Nz, ie, ol, Kein yan Een ofipeinn men hry ne exo ‘Spoev mmo aes «Reopen net Baht gsoniy ei trawtite de [reed pps nin bento a, hesosanrete, deg “cat Car Med 200%