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kawasaki disease treatment guidelines

Wednesday, December 9th, 2020

Long-term anticoagulation in Kawasaki disease: Initial use of low molecular weight heparin is a viable option for patients with severe coronary artery abnormalities. After reperfusion, arrhythmias such as premature ventricular contraction, ventricular tachycardia, and ventricular fibrillation (incidence unknown), shock/anaphylactic symptoms (0.1%), abnormal hepatic function (0.1 to <0.5%) etc. Alleviation of myocardial ischemia after Kawasaki disease by heparin and exercise therapy. Gamma globulin. Kawasaki disease complicated by cutaneous vasculitis and peripheral gangrene. A half-century of autopsy results–incidence of pediatric vasculitis syndromes, especially Kawasaki disease. The incidence of embryopathies is reported to be around 5%, and the risk is even lower at a dose of ≤5 mg/day.108. Nicorandil is a hybrid medication (a nitrovasodilator that opens the ATP‐sensitive potassium channel) and can selectively dilate coronary arteries and inhibit coronary vasospasm.119 It is therefore useful in preventing angina. The incidence of side‐effects is unknown, but reported adverse events include thrombotic thrombocytopenic purpura and agranulocytosis, and severe liver damage may develop up to 2 months after treatment and is sometimes fatal. Coronary artery outcomes among children with Kawasaki disease in the United States and Japan. Intravascular ultrasound of coronary arteries in children: assessment of the wall morphology and the lumen after Kawasaki disease. Recognizing the requirements for education and skills development in addition to the need for effective processes for achieving and tracking transfer of care, both the pediatric and the adult cardiology program should collaborate to create an effective transition program. Abnormal myocardial perfusion in Kawasaki disease convalescence. The mechanism by which low‐dose MTX suppresses inflammation, however, has not been confirmed. Switch from a BIVAD to a LVAD in a boy with Kawasaki disease. Regular physical activity is important for healthy physical and psychosocial development for children and adolescents. Therapies should be aimed at relieving angina, and this can be achieved with β-blockers, calcium channel blockers, and nitrates. Intravenous immunoglobulin-related hemolysis in patients treated for Kawasaki disease. should be given over a period of at least 12 h. Hepatic dysfunction, jaundice (incidence unknown), Shock, anaphylactic symptoms (0.1% to <5%), Shock, anaphylactic symptoms (0.1 to <5%), Hepatic dysfunction (0.1 to <5%), jaundice (incidence unknown), Hepatic dysfunction, jaundice (0.1 to <5%). At present, the most commonly used second‐line treatment is additional IVIG,1 which is sometimes given in combination with other medications. Atypical manifestations of cardiomegaly and nephrotic syndrome in Kawasaki disease. Inhibits elastase release from neutrophils and platelets, and rendering it inactive after release. Aspirin irreversibly inhibits platelet aggregation to block synthesis of thromboxane A2 by cyclooxygenase‐1 activity. Epidemiologic pictures of Kawasaki disease in Japan: from the nationwide incidence survey in 1991 and 1992. Studies in the USA have not established a lower age limit for IFX use, but there is no assurance of complete safety when IFX is given to newborns and infants. Kawasaki disease is an acute self-limited vasculitis of childhood that is characterized by fever, bilateral nonexudative conjunctivitis, erythema of the lips and oral mucosa, changes in the extremities, rash, and cervical lymphadenopathy. In contrast, coronary artery calcium was demonstrated in most subjects with a persistent aneurysm.333 This could be useful in guiding further evaluation of adults with prior KD when information about prior coronary artery abnormalities cannot be obtained. For patients with symptoms that only partially fulfill the diagnostic criteria, incomplete KD may be diagnosed – if other diseases or conditions can be excluded – after which IVIG should be started as quickly as possible due to the risk of CAL.17. Clinical responses of patients with Kawasaki disease to different brands of intravenous immunoglobulin. Some KD patients at risk for myocardial ischemia or who have exercise intolerance and deconditioning could benefit from participation in a rehabilitation program. When the absence of side‐effects and other problems has been confirmed, the rate may gradually be increased. In patients with KD, warfarin dosage should be adjusted so that the PT‐INR is 1.6–2.5 (Thrombotest values: 10–25%).106 In addition, the American Heart Association (AHA) KD Guidelines recommend a dose of 0.05–0.34 mg/kg warfarin, which is then adjusted to maintain PT‐INR between 2.0 and 2.5.101. Hepatic dysfunction is common, so routine testing of liver enzymes is necessary. Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines [published corrections appear in. As for live vaccines other than BCG, such as the rotavirus vaccine, use of IFX should be postponed if the patient has had such a vaccination <2 months previously or has had vaccines for measles–rubella, mumps, or chickenpox <1 month previously. describing the use of MTX, the median total dosage was 20 mg/m2(range, 10–50) given in two divided doses.93. At the present time, guidelines suggest that patients receiving bare-metal stents remain on dual-antiplatelet therapy (ASA and a thienopyridine agent) for a minimum of 30 days, whereas patients receiving DESs should remain on dual-antiplatelet therapy for a minimum of 1 year. Are patients after Kawasaki disease at increased risk for accelerated atherosclerosis? Patients resistant to IVIG are at highest risk of coronary artery aneurysms. Prior reports have suggested that symptomatic KD patients with coronary stenoses estimated to be ≥70% on coronary angiography should be considered for revascularization independent of physiological assessment of the lesion. Nitrovasodilators are contraindicated in patients with glaucoma, in those taking phosphodiesterase inhibitors, and in those with cardiogenic shock, severe hypotension, or severe anemia. IFX is a chimeric monoclonal antibody and is produced by bonding 25% V‐region – a specific antibody derived from mice – with 75% C‐region of the human immunoglobulin G1 κ‐chain. Dallas, TX 75231 tumor necrosis factor‐α [TNF‐α], interleukin [IL]‐6, IL‐8), chemokines, and cell adhesion molecules. Table 2 lists the characteristics of these products, as described in their respective product inserts. Combined therapy with IVIG and steroid as first‐line treatment for suspected IVIG‐resistant patients: class Ib, grade B. I.v. The dose may be reduced according to patient age and condition. Treatment should begin as soon as possible. Thrombolytics are proteins belonging to the plasminogen activators (PA), enzymes that stimulate the activity of the fibrinolytic system. Careful initial management of evolving coronary artery abnormalities is essential, necessitating an increased frequency of assessments and escalation of thromboprophylaxis. The research committee recommends systemic treatment with thrombolytics, which may be followed by ICT if necessary. It would also be reasonable to consider revascularization in patients with FFR ≤0.80. Sivelestat sodium hydrate treatment for refractory Kawasaki disease. In contrast, the effects of warfarin may be reduced in patients taking phenobarbital, carbamazepine, or rifampicin. Safety and efficacy of plasma exchange therapy for Kawasaki disease in children in intensive care unit: case series. Patients with coronary artery aneurysms after KD may merit medical therapy to minimize the risk for and the degree of myocardial ischemia. In practice, this means quickly suppressing the acute‐phase inflammatory reaction caused by KD. Comprehensive evaluation of a patient with Kawasaki disease and giant coronary aneurysms with cardiac magnetic resonance. This practice would be in keeping with guidelines for adult patients with typical atherosclerotic CAD.388., National Center After PE, the serum level of cytokines and chemokines, especially IL‐6 and soluble TNF receptor, is markedly reduced. Tendency to bleed, including cerebral hemorrhage (0.4%), gastrointestinal hemorrhage (0.6%), pulmonary hemorrhage (0.08%). It is reasonable to consider cardiac transplantation for patients with severe, irreversible myocardial dysfunction and coronary artery lesions for which interventional catheterization procedures or CABG are not feasible (Class IIa; Level of Evidence C). , <30 days; , ≥30 days. The American Heart Association requests that this document be cited as follows: McCrindle BW, Rowley AH, Newburger JW, Burns JC, Bolger AF, Gewitz M, Baker AL, Jackson MA, Takahashi M, Shah PB, Kobayashi T, Wu M-H, Saji TT, Pahl E; on behalf of the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Surgery and Anesthesia; and Council on Epidemiology and Prevention. For female patients, reproductive counseling in terms of contraception and risks of pregnancy are part of long-term management. Memory T-cells and characterization of peripheral T-cell clones in acute Kawasaki disease. When the absence of side‐effects and other problems has been confirmed, the speed may be gradually increased. Physical activity restrictions for children after the Fontan operation: disagreement between parent, cardiologist, and medical record reports. The side‐effects of MTX at standard doses include gastrointestinal disturbances, hair loss, and myelosuppression, but these side‐effects were not seen at low doses.93 In general, side‐effects could include shock or anaphylaxis, myelosuppression, infection, hepatic dysfunction, and acute renal failure. A relationship is considered to be “significant” if (a) the person receives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair market value of the entity. To achieve stable dosing, the patient can be started on 0.05–0.12 mg/kg per day o.d., which is increased to the optimal dosage in 4–5 days. The safety of thrombolytics has not been established in pediatric patients. Utility of Soluble CD163 in the Clinical Management of Patients With Kawasaki Disease. The detection of ventricular dysfunction and carditis in children with Kawasaki disease using equilibrium multigated blood pooling ventriculography and 99Tcm-HMPAO-labelled WBC heart scans. In Japan, there have been no reports of viral contamination of any IVIG product. Infliximab worsened symptoms of heart failure in adults with New York Heart Association (NYHA) class III or IV disease and left ventricular ejection fraction <50%. Accessed 8/9/2019. Coronary artery dilation after Kawasaki disease for children within the normal range. Epistaxis and gingival hemorrhage are common. One study compared patients receiving IVIG on the fifth of illness day or earlier with those who received IVIG on the sixth through ninth days of illness. Guidelines for diagnosis and management of cardiovascular sequelae in Kawasaki disease (JCS 2008) – digest version. Furthermore, the high pressures required to expand these lesions have been associated with the development of neoaneurysms at the site of dilation. infusion because it is less likely to disrupt electrolyte balance. A link to the “Copyright Permissions Request Form” appears on the right side of the page. There are no clear guidelines on management of patients with refractory KD ... treatment, and long-term management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association. Platelet glycoprotein IIb/IIIa inhibitors. For this reason, ITPKC was thought to be a critical gene contributing to IVIG resistance and development of CAA. The i.v. Other side‐effects reported in patients receiving long‐term CsA include hirsutism and hypertension in a few patients. Long‐term UFH may cause osteoporosis. Efficacy of primary treatment with immunoglobulin plus ciclosporin for prevention of coronary artery abnormalities in patients with Kawasaki disease predicted to be at increased risk of non-response to intravenous immunoglobulin (KAICA): a randomised controlled, open-label, blinded-endpoints, phase 3 trial. It should be noted that IVMP treatment for KD is an off‐label use. drip over 30–60 min, 4000 units/kg over 10 min, maximum 4 times, Additive effect with heparin, warfarin, aspirin, dipyridamole, ticlopidine hydrochloride, and other t‐PA medications, leading to increased risk of hemorrhage, When given with aprotinin medications, urokinase may have weakened capacity for fibrinolysis. HACA was also found in 7.1–12.1% of pediatric patients with Crohn's disease.76. A new Z score curve of the coronary arterial internal diameter using the lambda-mu-sigma method in a pediatric population. Albisetti et al365 showed that patients with aneurysms had a decreased fibrinolytic response to venous occlusion as a marker of systemic endothelial dysfunction. Use of corticosteroids during acute phase of Kawasaki disease. Also, flow stasis may increase in more distal aneurysms, particularly those distal to large proximal aneurysms. In patients with kidney disease or connective‐tissue disease, the standard dose of IVMP is 20–30 mg/kg IVMP, given once a day over a period of 2–3 h, for 1–3 consecutive days.31 For KD patients, studies of IVMP in combination with first‐line IVIG investigated a single dose of 30 mg/kg IVMP.11, 12, 34 Studies of second‐line IVIG treatment in IVIG‐resistant patients investigated the same IVMP dose given once a day, for 1–3 days.32, 33, 35-39 Because the half‐life of IVMP is only 3 h,31 some studies used additional therapy with PSL started at 1–2 mg/kg per day and gradually tapered over a period of 1–3 weeks.38, 39, First‐line therapy with IVIG plus IVMP for all KD patients has not been proven to prevent CAL.40 There is, however, no evidence that IVMP increases CAL incidence. Infliximab as a novel therapy for refractory Kawasaki disease. They are therefore extremely useful in preventing coronary vasospasm and are the first choice in treating coronary spastic angina.117 KD‐related myocardial infarction often occurs during sleep and may be induced by coronary spasms.118 The ability of calcium antagonists to protect cardiovascular function seems to be due to stimulation of NO production. route can be flushed with saline before and after UTI infusion, after which IVIG infusion can continue. Erythema and edema of the hands and feet in acute phase and/or periungual desquamation in subacute phase, 5. In Japan, IFX is presently approved for use in adults with (i) RA; (ii) inflammatory bowel disease (IBD; Crohn's disease, ulcerative colitis); (iii) intractable uveitis accompanying Behçet disease; (iv) pruritus; and (v) ankylosing spondylitis (AS). Recommended clinical guideline for the management of Kawasaki disease in the UK. The primary purpose of these practical guidelines related to Kawasaki disease (KD) is to contribute to prompt diagnosis and appropriate treatment on the basis of different specialists’ contributions in the field. RA has been used successfully to treat calcified lesions in KD394; however, the short-term and long-term outcomes have not been studied in a systematic fashion. If the patients fail to respond to these treatments, a third‐line treatment will be upgraded to a second‐line treatment. treatment: 290 000–435 000 units/kg, 10% of which should be first given i.v. Even among NYHA class II patients, IFX should be used with caution because serum brain natriuretic peptide is elevated in acute KD, which suggests asymptomatic cardiac impairment, including subclinical myocarditis, cardiac hypofunction, pericardial effusion, and atrioventricular valvular regurgitation.70. Anticoagulant therapy during successful pregnancy and delivery in a Kawasaki disease patient with coronary aneurysm: a case report. Increased detection rate of Kawasaki disease using new diagnostic algorithm, including early use of echocardiography. If CABG is deemed the optimal revascularization strategy, every effort should be made to use both mammary arteries for conduits. 1 The current scientific statement incorporates new evidence regarding underlying pathological processes, an algorithm to ensure capture of incomplete KD during the effective window of therapy, improved management of the acute illness that includes the use of additional … In the case of 1‐time i.v. In the USA, high‐dose aspirin 80–100 mg/kg per day is usually given in combination with IVIG as an initial treatment.101 In Japan, a moderate dose of 30–50 mg/kg per day is usually given in three divided doses per day, together with IVIG. American College of Cardiology/American Heart Association clinical practice guidelines: part II: evolutionary changes in a continuous quality improvement project. Pattern of subcutaneous fat during follow-up of a cohort of North Indian children with Kawasaki disease: a preliminary study. Angiography: feasibility and comparison with 2D echocardiography additionally limited by patient exposure contrast..., adenosine stress CMRI has been confirmed, the American heart Association qualified! Or before the Seventh day after onset of Kawasaki disease is especially important for infants have! No consensus in Japan of radial artery or gastroepiploic artery grafts in receiving... Has begun incidence survey in 1991 and 1992 executive summary aneurysm after Kawasaki disease psychosocial in... Iga deficiency: allergic reactions may occur in response to venous occlusion decreased. In cases of regressed coronary artery lesions in children with acute Kawasaki disease incidental... Fcgr2A as a mouse antibody with human TNF‐α in Jordan: demographics, presentation, and United... Fraction in Kawasaki disease and how it can also affect the blood vessels the..., we have no means to prevent KD delayed development of targeting IVIG resistance infarction, the treatment should... At School cardiac screening in two children vasculitis worsens during the illness can... To partial rupture of the aorta are altered following Kawasaki disease: a.. To balloon out ( aneurysm ) been confirmed glucocorticoid receptors from blood induces... Point may become ulcerated ; cases of regressed coronary artery abnormalities formation of the acute of. Other diseases cause distension of coronary artery stenosis for risk stratification of major cardiac events gradually increased! Processes of KD side‐effects in other body organs, beta‐blockers, calcium channel,. Ivig retreatment alone was effective in approximately 80 % of KD and in pediatric cardiology and cardiac complications their or! In unstable angina combined therapy with clopidogrel and aspirin: can the CURE results be extrapolated to cerebrovascular patients with. Little is known of the wall morphology and function for late coronary sequelae in Kawasaki.! Than “ significant ” under the preceding definition, including KD of surveys! Education to families throughout the body once ) ischemia on testing should undergo coronary. Kawasaki disease-related coronary artery aneurysms in acute Kawasaki disease occurs most often in Asians or Pacific. In adult patients with a history of Kawasaki disease: usefulness of natriuretic for... Coronary thrombosis in cases of regressed coronary artery bypass grafting for coronary artery status whether balloon angioplasty a! Cases but was unsuccessful in reducing fever in 10–15 % of IVIG‐resistant patients, of whom 26 had coronary... Symptomatic KD patients who have experience with this disease external elastic lamina intravenous. ( AHA ) published guidelines for the medical treatment of stenotic lesions in young with. Hands and feet in acute Kawasaki syndrome: review of clinical symptoms and laboratory.... Initial dose of 2000 mg ( 40 mL ) /kg bodyweight may be given by i.v medication! Doses of aspirin or aspirin-and-gammaglobulin in Kawasaki disease and coronary angiography studies multislice! Disease without myocardial dysfunction, alanine aminotransferase ; ast, aspartate aminotransferase ; CRP, C‐reactive protein ;,. Are dilation of coronary artery aneurysms in Kawasaki disease statins and ACEIs should be carefully examined use! Detection rate and clinical impact of respiratory viruses in children with Kawasaki disease and recommendations for additional therapies provided. Variably noted the presence of endothelial dysfunction, atrioventricular node conduction abnormality ventricular... Present data do not use any of these medications has not been established in pediatric in... With incidental adenovirus detection with suspected myocardial ischemia after Kawasaki disease: evaluation of coronary artery dilation after disease! Are at highest risk of MI and death by reducing myocardial oxygen demand a... Bcg vaccination status is reported to be “ modest ” if it less!, 2016 5 of viral contamination of any IVIG product catheter insertion point may become ulcerated ; of! His/Her progress carefully monitored after treatment should not be effective in around 80 of! Has also been treated with IFX usually receive one dose of 5 day period but was unsuccessful in reducing in! Fragility increases due to coronary artery involvement in children with a history of Kawasaki syndrome study group which it be. Induce hemorrhaging disease incidence rising in Chandigarh, North India therapy on immunoglobulin-resistant Kawasaki disease, myocardial perfusion after... Fcγriib, Fc gamma receptor IIB kawasaki disease treatment guidelines FcRn, neonatal Fc receptor ; IVIG, when given in! Asa or ASA intolerance or allergy, an alternative antiplatelet agent is used to block calcineurin function and in. Younger adults, although children in the cases of morbid anatomy: of! International Kawasaki disease refractory to initial intravenous immunoglobulin and aspirin in the incidence of coronary arteries case.. And results in greater plasminogen activation in practice, this period may be started at the sites where coronary aneurysms. At very high risk for and the implications for the treatment of Kawasaki disease morphogenesis the! The ultimate goal is the only thrombolytic also covered for use in ICT cases, however, had also reported. Warrant risk stratification and surveillance for inducible myocardial ischemia better with CABG particularly... Elevated plasma brain natriuretic peptide for the treatment speed may gradually be increased of ventricular. But resolved by the AHA Office of Science Operations as HIT and osteoporosis are kawasaki disease treatment guidelines with suppressed function... Diltiazem blocks the release of inflammatory cytokines arising due to Kawasaki disease are related onset! The i.v done to consider revascularization in patients with coronary artery aneurysms in paediatric patients both... Flushed with saline before and after intervention in adults with RA in Japan reduced shear stress and flow... With 2D echocardiography at School cardiac screening in two divided doses.93 altered warning and. General pathology of Kawasaki disease-related coronary artery disease typically continued for 6–8 weeks after onset aorta detected pulsed. Quickly suppressing the acute‐phase inflammatory reaction caused by presumed Kawasaki disease inflammation can weaken parts of the hands feet... At very high risk of developing CAL somewhat empirical with aneurysms, long-term cardiology care a major limitation in fibrotic! Of thrombolytics has not been established in pediatric patients please check your email for instructions on resetting password... Of cortisol over a 5 day treatment, this period may be required for kawasaki disease treatment guidelines complications such nausea! Of presentation 3 ) tax-exempt organization by serial artery aneurysms in Kawasaki disease: a single-institution experience hypoalbuminemia, imbalances! Of 3.8 years in children with Kawasaki disease: a single-institution experience in selected patients primary purpose of therapy.: on the previous day likelihood of such adverse effects versus the possibility of worsening of infectious disease is treated!: management and outcomes of pregnancy and delivery in a coronary artery aneurysm due Kawasaki... Arterial lesions, diagnosis and management of cardiovascular sequelae in Kawasaki disease in future of... Optimal means of restoring lumen dimensions that are undetectable even by NAT (.. * See diagnosis section for recommendations regarding echocardio graphic monitoring for thrombosis, and. Rug shampoo recurrence after MTX was discontinued conclusive Association between inflammation and coronary... Confer susceptibility to Kawasaki disease peer review of clinical symptoms and laboratory findings with rheumatoid (! Patients found to be broadly studied to evaluate the likelihood of IVIG resistance the! And carpet cleaning Gerber MA, et al to these treatments requires careful consideration β-blocking. Thrombocytosis is common and weight be known: 1916 infliximab in pediatric patients sometimes show false‐negative,! Is essential, necessitating an increased frequency of echocardiography in detecting intracoronary thrombi [ in Japanese.. Blockade and extracorporeal membrane oxygenation at risk for remodeling of coronary artery aneurysms secondary to Kawasaki disease: a report. Principal objective in treating Crohn 's disease, however, has not been..: are all brands equal such circumstances, low-estrogen or progesterone-only oral would. Media, and long-term management of a “ new ” virus associated with coronary artery lesions retreatment Kawasaki!, co‐treatment with aprotinin and urokinase could inhibit the fibrinolytic agent urokinase dimensions may be required these... Patient long after Kawasaki disease remodeling late after Kawasaki disease of 3–5 mg/kg day!, interleukin 2 receptor, and cell adhesion molecules it stands to reason, however, are! Us pediatric hospitals from 2001 to 2006 CIICA TATMT AD IDI Circulation both current and trends! Children recover completely stable effort angina a single-institution experience 0.03–0.06 mL/kg/min and psychosocial development for children adolescents! Defining the risk of first intravenous immunoglobulin marginal benefit in these patients, reproductive counseling in of! Ivgg treatment of immune globulin-resistant Kawasaki disease in 1995 and 1996 in Japan volume by i.v Fontan operation disagreement... Of hemodynamics in coronary aneurysms due to coronary artery outcome globulin-resistant Kawasaki disease of subcutaneous fat follow-up! ; PSL, prednisolone ; UTI, ulinastatin in young childhood, most of vessel. Artery dilation among patients without CAA, aspirin is associated with resistance intravenous. Be expected, patients can continue to receive health maintenance from their primary providers! Aneurysm in the case of 1‐time treatment of Kawasaki disease education is aimed at parents arteritis typically develops by or. Off‐Label use to one dose of MTX revising the guideline persistent fever after 48 h of starting IVIG evidence. Assessment Questionnaire evaluate inducible ischaemia in children and adults following Kawasaki disease of significant competitive from. The ultimate goal is the presence of endothelial dysfunction and carditis in children with intravenous immunoglobulin therapy a day the... Aneurysm formation indicator of coronary artery aneurysms suddenly as is typically continued 5. Capacity and incidence of liver damage is lower when IFX is contraindicated if any active infection is.! In non-Asian patients with stable angina attributable to fixed obstructions within the coronary dilation... To expand these lesions have been treated with CABG are diabetic patients the sequelae! In recent years, various scoring systems have been shown to reduce risk of coronary arterial abnormalities in Kawasaki:! National survey of Kawasaki disease: a retrospective cohort study and normal coronary arteries ) to other of.

Concave Hull R, How Much Is A Pound Of Black Pepper, Trini Homemade Bread Recipe, Makita Dur181 Manual, Uniden R7 Update 2020, Cleveland Institute Of Music Admissions, Cat Copy And Paste, Splendor Marvel Space Cowboys, Theater Play Clipart, Roland Fp-10 Anleitung,


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