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 a LANGE medical book

CURRENT
Pediatric Diagnosis
& Treatment
17th Edition
Edited by

William W. Hay, Jr., MD Judith M. Sondheimer, MD

Professor, Department of Pediatrics Professor, Department of Pediatrics, and Head, Section
Section of Neonatology and the Division of Perinatal of Pediatric Gastroenterology, Hepatology, and Nutrition
Medicine and Research University of Colorado School of Medicine and
University of Colorado School of Medicine and The Children’s Hospital, Denver
The Children’s Hospital, Denver
Robin R. Deterding, MD
Myron J. Levin, MD Associate Professor, Department of Pediatrics, Section of
Professor, Departments of Pediatrics and Medicine Pediatric Pulmonary Medicine
University of Colorado School of Medicine and University of Colorado School of Medicine and
The Children’s Hospital, Denver The Children’s Hospital, Denver

and Associate Authors

The Department of Pediatrics at the University of
Colorado School of Medicine is affiliated with
The Children’s Hospital of Denver, Colorado.

Lange Medical Books/McGraw-Hill

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Contents
Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix

1. The Newborn Infant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Elizabeth H. Thilo, MD, & Adam A. Rosenberg, MD
Evaluation of the Newborn Infant History 1 Infections in the Newborn Infant 49
Care of the Well Newborn Infant 8 Hematologic Disorders in the Newborn Infant 58
Common Problems in the Term Newborn Infant 11 Renal Disorders in the Newborn Infant 61
Neonatal Intensive Care 26 Neurologic Problems in the Newborn Infant 62
Cardiac Problems in the Newborn Infant 43 Metabolic Disorders in the Newborn Infant 64
Gastrointestinal & Abdominal Surgical Conditions in the Newborn
Infant 46

2. Child Development & Behavior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Edward Goldson, MD, & Ann Reynolds, MD
Normal Development 66 Common Developmental Concerns 86
Behavioral & Developmental Variations 85 Developmental Disorders 93
Normality & Temperament 85

3. Adolescence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
David W. Kaplan, MD, MPH, & Kathryn Love-Osborne, MD
Guidelines for Adolescent Preventive Services 104 Breast Disorders 125
Growth & Development 113 Gynecologic Disorders in Adolescence 128
Behavior & Psychological Health 115

4. Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147

Paritosh Kaul, MD, & Catherine Stevens-Simon, MD
Scope of the Problem 147 Predicting the Progression From Use to Abuse 155
Morbidity Associated with Substance Abuse 152 Management of Substance Abuse 156
Supplement Use and Abuse 154 Treatment & Referral 160
Response to the Problem 155 Prevention of Substance Abuse 164

5. Eating Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165

Eric J. Sigel, MD
Etiology 165 Complications 170
Incidence 166 Treatment 172
Predisposing Factors 166 Prognosis 175
Diagnosis 166

6. Child & Adolescent Psychiatric Disorders & Psychosocial Aspects of Pediatrics . . . . . . . . . . . . . . . 176
Jennifer Hagman, MD, & Donald W. Bechtold, MD
Psychosocial Aspects of Child Development & Family Life 176 Screening for Psychosocial Problems & Psychiatric Disorders Within
Challenges in Parenting Related to Child & Adolescent the Context of Health Maintenance Visits 184
Development 179 Psychiatric Disorders of Childhood & Adolescence 188
The Chronically Ill Child 182 Overview of Pediatric Psychopharmacology 210

iii
iv / CONTENTS

7. Child Abuse & Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221

Andrew P. Sirotnak, MD, & Richard D. Krugman, MD
Forms of Child Maltreatment 221 Management & Reporting of Child Abuse & Neglect 225
Recognition of Abuse & Neglect 222 Prevention of Child Abuse & Neglect 225

8. Ambulatory & Community Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227

Robert M. Brayden, MD, Matthew F. Daley, MD, & Jeffrey M. Brown, MD, MPH
Pediatric History 227 Other Types of General Pediatric Services 240
Pediatric Physical Examination 228 Common General Pediatric Issues 244
Health Supervision Visits 230

9. Immunization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
Matthew F. Daley, MD, Ann-Christine Nyquist, MD, MSPH, & Eric A. F. Simoes, MD, DCH
The Composition of Immunizing Agents 249 Passive Prophylaxis 282
Safety of Immunization 250 Legal Issues in Immunization 283
Vaccinations for Special Situations 276

10. Normal Childhood Nutrition & Its Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284

Nancy F. Krebs, MD, MS, Laura E. Primak, RD, CNSD, CSP,
& K. Michael Hambidge, MD, BChir, ScD
Nutritional Requirements 284 Pediatric Undernutrition 304
Infant Feeding 299

11. Emergencies & Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317

F. Keith Battan, MD, & Marsha S. Anderson, MD
I. Emergencies & Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
Advanced Life Support for Infants & Children 317 Burns 331
Emergency Pediatric Drugs 323 Hypothermia 334
Approach to the Seriously Ill Child 323 Submersion Injuries 335
Approach to the Pediatric Trauma Patient 325 Bites: Animal & Human 336
Head Injury 329
II. Bioterrorism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
Anthrax 337 Plague 343
Smallpox 340 Botulinum Toxin 344

12. Poisoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346

Richard C. Dart, MD, PhD, & Barry H. Rumack, MD
Management of Specific Common Poisonings 350

13. Critical Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 372

Todd C. Carpenter, MD, Emily L. Dobyns, MD, Stephanie N. Mateev, MD, Peter M. Mourani, MD,
Margaret A. Ferguson, MD, & Kurt R. Stenmark, MD
Acute Respiratory Failure 372 Brain Injury/Cerebral Edema 397
Mechanical Ventilation 377 Ethical Deliberation and End-of-Life Care in the PICU 401
Acute Respiratory Distress Syndrome 380 Nutritional Support of the Critically Ill Child 402
Asthma (Life-Threatening) 384 Pain & Anxiety Control 406
Shock 386
Indications for Central Venous and Arterial Cannulation 393
 CONTENTS / v

14. Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411

Joseph G. Morelli, MD, & William L. Weston, MD
General Principles of Diagnosis of Skin Disorders 411 Disorders of the Skin in Newborns 413
General Principles of Treatment of Skin Disorders 411 Common Skin Diseases in Infants, Children, & Adolescents 417

15. Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 432

Rebecca Sands, MD, Arlene Drack, MD, & Allan M. Eisenbaum, MD
Common Nonspecific Signs & Symptoms 432 Disorders of the Cornea 450
Refractive Errors 433 Disorders of the Lens 451
Examination 434 Disorders of the Retina 452
Ocular Trauma 438 Diseases of the Optic Nerve 454
Injuries to the Eyelids 439 Diseases of the Orbit 456
Disorders of the Ocular Structures 441 Nystagmus 457
Disorders of the Nasolacrimal System 443 Amblyopia & Strabismus 457
Diseases of the Conjunctiva 444 Unexplained Decreased Vision in Infants & Children 460
Disorders of the Iris 447 The Blind Child 460
Glaucoma 448 Learning Disabilities & Dyslexia 460
Uveitis 448 Vision Screening 460
Acquired Immunodeficiency Syndrome & the Eye 450

16. Oral Medicine & Dentistry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462

William A. Mueller, DMD
Oral Examination of the Newborn & Infant 462 Antibiotics in Pediatric Dentistry 469
Eruption of the Teeth 464 Special Patient Populations 469
Dental Caries & Periodontal Disease 466 Maternal-Fetal Relationship 470
Orofacial Trauma 468 Dental Referral 471
Dental Emergencies 469

17. Ear, Nose, & Throat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 472

Candice E. Johnson, MD, PhD, Peggy Kelley, MD, & Norman R. Friedman, MD
I. The Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 472
II. The Nose & Paranasal Sinuses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 488
III. The Throat & Oral Cavity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 494

18. Respiratory Tract & Mediastinum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 506

Gwendolyn S. Kerby, MD, Gary L. Larsen, MD, Frank J. Accurso, MD, Robin R. Deterding, MD,
Vivek Balasubramaniam, MD, & Scott D. Sagel, MD
Respiratory Tract 506 Acquired Disorders of the Intrathoracic Airways 518
Growth & Development 506 Congenital Malformations of the Lung 528
Diagnostic Aids 507 Acquired Disorders Involving Alveoli 531
General Therapy of Pediatric Lung Diseases 510 Diseases of the Pulmonary Circulation 544
Disorders of the Conducting Airways 511 Disorders of the Chest Wall 548
Congenital Disorders of the Extrathoracic Airway 512 Disorders of the Pleura & Pleural Cavity 549
Acquired Disorders of the Extrathoracic Airway 513 Disorders of the Control of Breathing 551
Congenital Disorders of the Intrathoracic Airways 517 Mediastinum 555

19. Cardiovascular Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 558

Anji T. Yetman, MD, Shelley D. Miyamoto, MD, & Henry M. Sondheimer, MD
Diagnostic Evaluation 558 Cardiac Transplantation 613
Congenital Heart Disease 571 Disorders of Rate & Rhythm 615
Acquired Heart Disease 599
vi / CONTENTS

20. Gastrointestinal Tract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 625

Judith M. Sondheimer, MD
Evaluation of the Child with Vomiting 625 Acute Abdomen 635
Gastroesophageal Reflux 625 Peritonitis 635
Achalasia of the Esophagus 626 Acute Appendicitis 636
Caustic Burns of the Esophagus 627 Intussusception 637
Hiatal Hernia 627 Foreign Bodies in the Alimentary Tract 638
Pyloric Stenosis 628 Anal Fissure 638
Peptic Disease 628 Inguinal Hernia 638
Congenital Diaphragmatic Hernia 629 Umbilical Hernia 639
Congenital Duodenal Obstruction 630 Tumors of the Gastrointestinal Tract 639
Congenital Intestinal Atresias & Stenoses 630 Acute Infectious Diarrhea (Gastroenteritis) 641
Annular Pancreas 631 Chronic Diarrhea 642
Intestinal Malrotation With or Without Volvulus 631 The Malabsorption Syndromes 643
Meckel Diverticulum & Omphalomesenteric Duct Remnants 632 Constipation 650
Duplications of the Gastrointestinal Tract 632 Gastrointestinal Bleeding 651
Congenital Aganglionic Megacolon (Hirschsprung Disease) 633 Recurrent Abdominal Pain 654
Chylous Ascites 634 Inflammatory Bowel Disease 654
Congenital Anorectal Anomalies 634

21. Liver & Pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 660

Ronald J. Sokol, MD, & Michael R. Narkewicz, MD
Liver 660 Wilson Disease (Hepatolenticular Degeneration) 683
Prolonged Neonatal Cholestatic Jaundice 660 Reye Syndrome (Encephalopathy with Fatty Degeneration
Intrahepatic Cholestasis 660 of the Viscera) 685
Progressive Familial Intrahepatic Cholestasis (Byler Disease) 668 Cirrhosis 686
Extrahepatic Neonatal Cholestasis 668 Portal Hypertension 688
Other Neonatal Hyperbilirubinemic Conditions (Noncholestatic Biliary Tract Disease 693
Nonhemolytic) 670 Pyogenic & Amebic Liver Abscess 695
Hepatitis A 673 Hepatoma 697
Hepatitis B 675 Liver Transplantation 698
Hepatitis C 677 Pancreas 699
Hepatitis D (Delta Agent) 678 Acute Pancreatitis 699
Hepatitis E 678 Chronic Pancreatitis 700
Other Hepatitis Viruses 678 Gastrointestinal & Hepatobiliary Manifestations of Cystic
Fulminant Hepatic Failure (Acute Massive Hepatic Necrosis, Fibrosis 701
Acute Liver Failure) 679 Syndromes with Pancreatic Exocrine Insufficiency 701
Autoimmune Hepatitis (Lupoid Hepatitis) 680 Isolated Exocrine Pancreatic Enzyme Defect 705
Steatohepatitis 682 Pancreatic Tumors 706

1-Antitrypsin Deficiency Liver Disease 682

22. Kidney & Urinary Tract. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 707

Gary M. Lum, MD
Evaluation of the Kidney & Urinary Tract 707 Renal Failure 718
Congenital Anomalies of the Urinary Tract 711 Inherited or Developmental Defects of the Urinary Tract 725
Hematuria & Glomerular Disease 712 Urinary Tract Infections 729
Diseases of the Renal Vessels 716

23. Neurologic & Muscular Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 732

Paul G. Moe, MD, & Tim A. Benke, MD, PhD
Neurologic Assessment & Neurodiagnostic Procedures 732 Disorders of Childhood Affecting Muscles 794
Disorders Affecting the Nervous System in Infants & Children 739 Miscellaneous Neuromuscular Disorders 805
Infections & Inflammatory Disorders of the Central Nervous
System 786
 CONTENTS / vii

24. Orthopedics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 810

Robert E. Eilert, MD
Disturbances of Prenatal Origin 810 Trauma 818
Growth Disturbances of the Musculoskeletal System 814 Infections of the Bones & Joints 821
Degenerative Problems (Arthritis, Bursitis, & Tenosynovitis) 817 Miscellaneous Diseases of Bone 827

25. Rehabilitation & Sports Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 829

Pamela E. Wilson, MD, & Dennis J. Matthews, MD,
Basic Principles 829
Common Sports Medicine Issues and Injuries 834

26. Rheumatic Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 846

J. Roger Hollister, MD
Juvenile Rheumatoid Arthritis (Juvenile Chronic Arthritis) 846 Polyarteritis Nodosa 852
Spondyloarthropathy 848 Scleroderma 852
Enteropathic Arthritis 849 Raynaud Phenomenon 852
Systemic Lupus Erythematosus 849 Hypermobility Syndrome 853
Dermatomyositis (Polymyositis) 851

27. Hematologic Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 855

Daniel R. Ambruso, MD, Taru Hays, MD, Peter A. Lane, MD, & Rachelle Nuss, MD
Bone Marrow Failure 855 Bleeding Disorders 885
Anemias 858 Thrombotic Disorders 898
Polycythemia & Methemoglobinemia 879 Splenic Abnormalities 900
Disorders of Leukocytes 880 Transfusion Medicine 900

28. Neoplastic Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 911

Edythe A. Albano, MD, Mylène Bassal, MDCM, Christopher C. Porter, MD, Brian S. Greffe, MD,
Nicholas K. Foreman, MD, & Linda C. Stork, MD
Major Pediatric Neoplastic Diseases 911

Douglas K. Graham, MD, PhD, Roger H. Giller, MD, & Ralph R. Quinones, MD
Hematopoietic Stem Cell Transplantation 939 Late Effects of Pediatric Cancer Therapy 941

29. Immunodeficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 944

Anthony R. Hayward, MD, PhD
Nonspecific Factors in Resistance to Infection 944 Other Disorders Associated with Immunodeficiency 954
Deficiencies of Specific Immunity 946 Secondary Immunodeficiency 956
Combined Immunodeficiency Disorders 952 Investigation of Immunodeficiency 958

30. Endocrine Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 961

Philip S. Zeitler, MD, PhD, Sharon H. Travers, MD, Jennifer Barker, MD, Kristen Nadeau, MD,
& Michael S. Kappy, MD, PhD
General Concepts 961 Disorders of Calcium Homeostasis 979
Disturbances of Growth 963 The Gonads (Ovaries & Testes) 987
The Posterior Pituitary Gland 971 Adrenal Cortex 995
The Thyroid Gland 973
viii / CONTENTS

31. Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1006

H. Peter Chase, MD, & George S. Eisenbarth, MD, PhD
General Considerations 1006 Treatment 1007
Etiology 1006 Laboratory Evaluations 1010
Prevention 1007 Acute Complications 1011
Diagnosis 1007 Chronic Complications 1013

32. Inborn Errors of Metabolism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1014

Carol L. Greene, MD, Janet A. Thomas, MD, & Stephen I. Goodman, MD
Diagnosis 1014 Disorders of Fatty Acid Oxidation & Carnitine 1030
Management of Metabolic Emergencies 1018 Lysosomal Diseases 1033
Newborn Screening 1018 Peroxisomal Diseases 1033
Disorders of Carbohydrate Metabolism 1019 Carbohydrate-Deficient Glycoprotein Syndromes 1036
Primary Lactic Acidemias & Other Disorders of Energy Smith—Lemli—Opitz Syndrome and Disorders of Cholesterol
Metabolism 1021 Synthesis 1036
Disorders of Amino Acid Metabolism 1022 Disorders of Neurotransmitter Metabolism 1037
Organic Acidemias 1027

33. Genetics & Dysmorphology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1039

Ellen Roy Elias, MD, Anne Chun-Hui Tsai, MD, MSc, & David K. Manchester, MD
Principles of Genetics 1039 Mendelian Disorders 1064
Foundations of Genetic Diagnosis 1039 Nonmendelian Inheritance 1069
Principles of Inherited Human Disorders 1048 Multifactorial Inheritance 1071
Dysmorphology and Human Embryology 1056 Common Recognizable Disorders with Variable or Unknown
Clinical Features of Common Genetic Disorders 1061 Cause 1074
Chromosomal Disorders: Abnormal Number 1061 Perinatal Genetics 1076
Sex Chromosomes 1062 Evaluation of the Developmentally Delayed Child 1078
Chromosomal Abnormalities: Structural 1063

34. Allergic Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1080

Mark Boguniewicz, MD
The Allergic Cascade 1080 Urticaria & Angioedema 1098
Major Allergic Disorders Seen in Pediatric Practice 1080 Anaphylaxis 1100
Asthma 1080 Adverse Reactions to Drugs & Biologicals 1102
Allergic Rhinoconjunctivitis 1091 Food Allergy 1107
Atopic Dermatitis 1094 Insect Allergy 1108

35. Antimicrobial Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1110

John W. Ogle, MD
Principles of Antimicrobial Therapy 1110 Prophylactic Antimicrobial Agents 1119
Antimicrobial Susceptibility Testing 1111 Initial Empiric Antimicrobial Choices for Selected
Alteration of Dose & Measurement of Blood Levels 1113 Conditions 1121
The Use of New Antimicrobial Agents 1119 Specific Antimicrobial Agents 1122

36. Infections: Viral & Rickettsial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1130

Myron J. Levin, MD, & Adriana Weinberg, MD
I. Viral Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1130
Respiratory Infections 1130 Viral Infections Spread by Insect Vectors 1157
Infections Due to Enteroviruses 1142 Other Major Viral Childhood Exanthems 1162
Infections Due to Herpesviruses 1146 Infections Due to Other Viruses 1166

II. Rickettsial Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1170

 Another Random Document on
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