trauma-list Digest, Vol 59, Issue 3
Angela Johnson
angie504 at hotmail.com
Sun May 4 00:54:56 BST 2008
Kelly ,
We have on-line ceu's for Trauma and other Florida RN requirement classes on our hospital website . For our Trauma CEU's we use on-line courses from our hospital website, that links to the Tampa General Hospital website. I don't think you can access them without an employee number. I can ask my educator more specifics if you need. Hope this helps!
Angela
Ryder Trauma Center
----------------------------------------
> From: trauma-list-request at trauma.org
> Subject: trauma-list Digest, Vol 59, Issue 3
> To: trauma-list at trauma.org
> Date: Sat, 3 May 2008 12:07:33 +0100
>
> Send trauma-list mailing list submissions to
> trauma-list at trauma.org
>
> To subscribe or unsubscribe via the World Wide Web, visit
> http://list.mistral.net/mailman/listinfo/trauma-list
> or, via email, send a message with subject or body 'help' to
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>
> When replying, please edit your Subject line so it is more specific
> than "Re: Contents of trauma-list digest..."
>
>
> Today's Topics:
>
> 1. RE: Two trauma scenarios (Bjorn, Pret)
> 2. Survival as a quadriplegic (Stephen Richey)
> 3. CEUs for nursing staff (Gettig, Kelly S.)
> 4. Unusual Case (Matthew Reeds)
> 5. RE: trauma-list Digest, Vol 58, Issue 26 (Robert F. Smith)
> 6. Re: unusual case (sjasmd at aol.com)
> 7. Aorta: dissection vs. transection (Ivan Hronek)
>
>
> ----------------------------------------------------------------------
>
> Message: 1
> Date: Fri, 2 May 2008 10:11:23 -0400
> From: "Bjorn, Pret"
> Subject: RE: Two trauma scenarios
> To: "Trauma & Critical Care mailing list"
> Message-ID:
>
> Content-Type: text/plain; charset="us-ascii"
>
> Don't know the specifics of your trauma system; but in Maine, case #2
> would be referred for review by the trauma center. The nature and level
> of review is at the joint discretion of the hospitals involved, but
> we've done on-site debriefings in far less alarming cases.
>
> See what your system allows for, and reiterate your concerns to the
> trauma center and trauma system administrator, or his/her local
> approximation. If you truly have a system, it has a performance
> improvement function. Find out who's in charge, and bird-dog it.
> Trusting your version of events, there's clearly plenty to be learned at
> all levels.
>
> Best of luck.
>
> Pret Bjorn, RN
> Bangor, ME USA.
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Jenny Moncur
> Sent: Thursday, May 01, 2008 8:11 PM
> To: ccm-l at ccm-l.org; trauma-list at trauma.org
> Subject: Two trauma scenarios
>
>
> These two cases occurred on my shift the other day (I am a dispatcher at
> the
> moment so was co-ordinating ambulance and retrieval responses). They
> represent the highs and lows of being a part of a health care system.
>
>
>
> Motor bike rider - lost control of his bike at a rural location just in
> front of an ambulance returning from an interhospital transport with
> three
> intensive care paramedics on board. They jumped out, pt was decerebrate
> with
> obvious closed head injury. Intubated, sedated, paralysed within 10
> minutes.
> A helicopter was just passing overhead and was directed to land nearby.
> Pt
> transferred to chopper within 10 more minutes. Landed at major trauma
> centre
> 15 mins later. Patient in trauma centre well within an hour from
> incident
> and now doing very nicely. Expected to make full recovery from closed
> head
> injury. I am not sure exactly what type of injury, but required
> neurosurgical management.
>
>
>
> Motor car driver - lost control of her car and was partially ejected
> with
> car rolling. Ambulance crews on scene within ten mins - just outside
> large
> rural town. Rapid extrication and transferred to local hospital - scene
> time
> under 20 mins. I tried to organise heli evacuation but unable to get
> rotary
> or fixed wing due to weather conditions. Intensive care ambulance crew
> in
> area directed to hospital to aid rapid road transfer to major trauma
> centre.
> Hospital refused to allow patient to be moved - they had to x-ray
> patient!!
>
> Three and a half hours later a surgeon calls me to say he has a 'time
> crtical' patient who needs a helicopter to fly to trauma centre. Still
> unable to provide air support (weather) so send IC paramedic crew to
> hospital to effect rapid road transfer. Apparently surgeon not notified
> by
> hospital until just before he had called me.
>
>
>
> Shortly after that I get a call from the paramedic at hospital to say
> that
> this 28 yr old woman has bilat small heamopneumo thoraces, avulsed left
> kidney, lacerated liver, torn spleen, suspected mesenteric artery
> injury.
>
> She is having large amounts of IV fluids and blood, but does not have
> chest
> tubes, urinary catheter, nasogastric tube or ETT. She spent the best
> part of
> three hours in x-ray and cat scan. No operative management and going
> downhill rapidly.
>
> I place a call to the trauma registrar at major trauma centre to see if
> he
> can speed things up. He is shocked to find out that patient still in
> clutches of local hospital and her conditon. Several phone calls between
> local hospital and trauma registrar trying to speed up transfer.
>
> Time elapsed now over four hours from initial injury.
>
> Paramedic calls me 30 mins later to say he has demanded an anaesthetist
> come
> in to intubate this patient as her resp status and conscious state
> worsening. As he has a two hour road trip to major trauma centre this is
> a
> resonable request.
>
> Patient finally escaped from local hospital 7 (seven) hours after intial
> injury. Intubated, ventilated, one chest tube placed, lots of fluid and
> blood products given but still very hypotensive and tachycardic.
>
> Able to get a chopper in the air at that stage - arrived at trauma
> centre 40
> mins later.
>
> Straight to theatre - over ten hours of operative management.
>
> Left nephrectomy, aortic repair where renal artery torn; splenectomy,
> hemicolectomy for mesenteric injury, liver packed - not sure what else.
> Pt
> doing very badly - developing ARDS, DIC, the whole works.
>
>
>
> These two cases demonstrate to me the highs and lows of our trauma
> system.
>
> The first patient could not have received quicker treatment unless he
> dropped his bike in the car park of the Alfred Hospital.
>
> The second had the misfortune to be taken to a hospital with a junior
> doctor
> in ED who did not understand the state Trauma System, and no FACEM.
> Surgeon
> not involved until way too late. The whole thing so frustrating and a
> young
> patient who has been seriously compromised by delay in receiving
> definitive
> surgical care.
>
>
>
> There are big rumblings going on at a medical level at the local
> hospital,
> so maybe something will improve.
>
> My ambos are limited to taking any patient there if we cannot get air
> support, as the next largest hospital with a FACEM is over 40 mins away.
> I
> finished my shift feeling very sad and frustrated.
>
>
>
> Jenny Moncur
>
> IC Paramedic currently in OpCen.
>
> Oz
>
>
>
>
>
>
>
>
>
>
>
>
>
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>
>
>
>
> ------------------------------
>
> Message: 2
> Date: Fri, 2 May 2008 11:23:10 -0400
> From: "Stephen Richey"
> Subject: Survival as a quadriplegic
> To: trauma-list at trauma.org
> Message-ID:
>
> Content-Type: text/plain; charset=ISO-8859-1
>
> What is the longest survival you have heard of for a quadriplegic? I have
> seen a case previously of a 21 year survival, but recently came across a
> case as a result of my research of a 37 year survival period. This to me
> seems to be extremely unusual, but I was wondering what some of the more
> experienced members of the list make of a survival such as this.
>
>
>
> --
> Stephen L. Richey, CRT
> Aviation Injury Research Project Leader
> Saginaw Valley State University
> Phone: 248-366-4452
>
>
>
> "You should never put off for tomorrow what you can do tonight, because you
> never know what is going to come in tomorrow."- Robert A. Fink, MD, FACS
>
>
> ------------------------------
>
> Message: 3
> Date: Fri, 2 May 2008 11:52:16 -0500
> From: "Gettig, Kelly S."
> Subject: CEUs for nursing staff
> To:
> Message-ID:
>
> Content-Type: text/plain; charset="us-ascii"
>
> We are in the process of developing annual education for staff nurses.
> They have all had TNCC and we would like to follow up on that with some
> type of yearly CEUs that they can do in our on-line learning center.
> Does anyone have something similar in existence already?
>
>
>
> Thank you.
>
>
>
> Kelly Gettig, RN, MSN, CPNP
>
> Trauma Services
>
> Dell Children's Medical Center of Central Texas
>
> 512-324-0000 ext. 86818 (office)
>
> 512-612-0886 (pager)
>
> kgettig at seton.org
>
>
>
>
>
> ------------------------------
>
> Message: 4
> Date: Fri, 2 May 2008 18:07:55 +0100
> From: "Matthew Reeds"
> Subject: Unusual Case
> To: "'Trauma & Critical Care mailing list'"
>
> Message-ID:
>
>
> Content-Type: text/plain; charset="us-ascii"
>
> The CXR concerns me and I would certainly be concerned regarding an aortic
> injury (especially given the mechanism of injury.) I have not seen the CT
> head scan so would need to see it to see how severe the SDH is clinically
> and whether or not this needs to be evacuated with Burr
> holes/craniotomy/decompressive craniectomy (latter if contusions are severe
> and causing problems.) If not severe from a head injury point of view, I
> would just ICP monitor in this respect. SAH would be treated with formal
> cerebral angiography to identify true blushes (reducing VOMIT) with
> appropriate embolisation. I would try and avoid going into his head if he
> has "many skull fractures" although I would ascertain this from the CT head
> first.
>
>
>
> Because he would get a formal cerebral angiogram, he would also get a form
> aortic & arch aortography at the same time - as the next step after CT
> thorax/aorta - to truly ascertain if there is any aortic injury/intimal
> dissection. I would need to see more slices of the CT thorax to get a better
> idea of what injuries the patient "probably" has, as the slices I have seen
> are inadequate for me to form a proper opinion. This doesn't really matter
> because I would want a formal angiogram anyway to decide further management.
> Regarding the aorta I would proceed from there depending upon what it
> showed. Some would opt for a delayed open repair (once he has improved from
> the head injury - given his young age and the concern of long term outcomes
> for stenting.) Others would opt for stenting given his co-morbidities
> (especially being swayed by the head injury) as this would be an ideal
> indication for stent deployment in others' opinions.
>
>
>
> Either way, keep ventilated (as per normal neuroITU care for head injuries)
> and maintain CPP (whilst reducing ICP) using minimal fluid resuscitation
> (e.g. 7.5% hypertonic saline +/- starch - better than mannitol.) We have
> adapted a lower target range for CPP than we previously used to. This makes
> keeping the BP as low as possible (from the potential aortic injury point of
> view) much easier. I would also put him on an IV beta-blocker such as
> labetolol to keep his BP down pending further treatment (if any) as a result
> of the aortic & arch angiography.
>
>
>
>
>
> Matthew
>
>
>
>
>
> -----Original Message-----
> From: daniel simon [mailto:danielsimonster at gmail.com]
> Sent: 01 May 2008 16:29
> To: trauma-list at trauma.org
> Subject: unusual case
>
>
>
> 43 year old motorcycle crash victim , on scene intubation for GCS of 5. On
>
> admission intubated and ventilated, B.P 130/80 P 82 sat 100% , GCS 7 (T) .
>
> PE: skin lacerations and central hematoma anterior neck - zone 1.
>
> Head CT - SAH, Frontal contusions,small Frontal SDH, many skull fractures.
>
> C-spine: fracture of C1
>
> Chest XR and relevant cuts from the chest CTA included.
>
> Abdominal CT normal
>
> What would you do now?
>
>
>
>
>
> ------------------------------
>
> Message: 5
> Date: Fri, 2 May 2008 16:47:27 -0400
> From: "Robert F. Smith"
> Subject: RE: trauma-list Digest, Vol 58, Issue 26
> To: "'Trauma & Critical Care mailing list'"
>
> Message-ID:
> Content-Type: text/plain; charset="us-ascii"
>
> According to my surgical better half, Dr. Roberts, it was Dr. Prasad of the
> University of Illinois/Cook County Hospital. The procedure is named after
> him.
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
> On Behalf Of Ahmed, Naveed
> Sent: Tuesday, April 29, 2008 4:11 PM
> To: trauma-list at trauma.org
> Subject: RE: trauma-list Digest, Vol 58, Issue 26
>
> Can any of you help me with a refrence, who was responsible for
> introducing loop clostomy with distal end stapled for complete
> diversion?, I think it was Dr Maull, I a have been trying to find that
> referance for days!
> Naveed Ahmed
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of
> trauma-list-request at trauma.org
> Sent: Tuesday, April 29, 2008 7:00 AM
> To: trauma-list at trauma.org
> Subject: trauma-list Digest, Vol 58, Issue 26
>
> Send trauma-list mailing list submissions to
> trauma-list at trauma.org
>
> To subscribe or unsubscribe via the World Wide Web, visit
> http://list.mistral.net/mailman/listinfo/trauma-list
> or, via email, send a message with subject or body 'help' to
> trauma-list-request at trauma.org
>
> You can reach the person managing the list at
> trauma-list-owner at trauma.org
>
> When replying, please edit your Subject line so it is more specific than
> "Re: Contents of trauma-list digest..."
>
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>
>
>
> ------------------------------
>
> Message: 6
> Date: Fri, 02 May 2008 21:34:00 -0400
> From: sjasmd at aol.com
> Subject: Re: unusual case
> To: trauma-list at trauma.org
> Message-ID:
> Content-Type: text/plain; charset="us-ascii"
>
> There is hemorrhage in the mediastinum on both the CT and the CXR. I think this is due to an injury? of the origin of the left common carotid artery. However the descending aorta is not shown on these images.
>
> I would perform a formal arteriogram of the aortic arch unless the entire CT clearly visualizes all potential injuries both axially and with reformations of the cTA.
>
> I am concerned about all the facial injury and the possibility of BCVI but would be quite hesitant to do the necessary selective carotid arteriography unless the arch study clearly excluded my suspected left carotid injury.
>
> If there is an isolated injury of the left common carotid artery anatomically amenable to a stent graft, this would be a good option that i would favor. If the arch or descending aorta is injured in addition to the LCCA, I would be happy not to have to make that decision.
>
>
>
>
>
>
>
>
> sal
>
>
> -----Original Message-----
> From: daniel simon
> To: trauma-list at trauma.org
> Sent: Thu, 1 May 2008 11:29 am
> Subject: unusual case
>
>
>
> 43 year old motorcycle crash victim , on scene intubation for GCS of 5. On
> admission intubated and ventilated, B.P 130/80 P 82 sat 100% , GCS 7 (T) .
> PE: skin lacerations and central hematoma anterior neck - zone 1.
> Head CT - SAH, Frontal contusions,small Frontal SDH, many skull fractures.
> C-spine: fracture of C1
> Chest XR and relevant cuts from the chest CTA included.
> Abdominal CT normal
> What would you do now?
>
>
>
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>
>
>
> [Image Removed]
>
>
> [Image Removed]
>
>
> [Image Removed]
>
>
>
> ------------------------------
>
> Message: 7
> Date: Fri, 2 May 2008 22:51:16 -0700 (PDT)
> From: Ivan Hronek
> Subject: Aorta: dissection vs. transection
> To: trauma-list at trauma.org
> Message-ID:
> Content-Type: text/plain; charset=iso-8859-1
>
> Ian, I agree that in trauma survivors a lesion at the level of the takeoff of the left subclavian artery is much more common then an ascending aortic injury:
>
> At the point of the greatest shearing force, the isthmus of the aorta, 95% of injuries are found; only 5% are detected in the ascending aorta. At the point of the greatest shearing force, the isthmus of the aorta, 95% of injuries are found; only 5% are detected in the ascending aorta. http://www.mdconsult.com/das/article/body/93775974-2/jorg=journal&source=&sp=984672&sid=0/N/47574/1.html?issn=0749-0704#H073308
>
> ________________________________
>
>
> http://radiology.rsnajnls.org/cgi/reprint/209/2/335
> In patients who survive long enough toreach the hospital, the most commonlocations of ATAIs are the aortic isthmus(in 80%-90% of patients), the ascending
> aorta (in 5-9%), and the diaphragmatic
> aorta (in 1%-3%) (4-6,19,26,49,63-71).Multiple aortic lacerations or concomi
> aontic branch vessel injuries occur in
> 6%-20%
> (2-4,7,8,56,64,72-82).In autopsy
> series (2,3,6-8,17,19,63,64,66,80,83,84),
> up to 22% of ATAIs are in the ascending
> aorta, death having been immediate and
> commonly associated with severe cardiactantand 4%-10% of cases, respectivelyinjuries (in 80% of cases), including pericardialtamponade, aortic valve tear, myocardialcontusion, and coronary artery injury.
>
> ________________________________
>
> However, the difference between the two entities has to do more with the etiology of the injury and the actual lesion can be similar: in both situations there is initially a tear/laceration of the aortic wall. This can then lead to a dissection(=longitudinal tear), transection(=circular tear), aortic intramural hematoma, pseudoaneurysm, periaortic hematoma, contained rupture etc. During the development of these steps the pathology on TEE can be similar - existence of true and false lumens, pulsations towards the false lumen, a jet at the point of entry of the blood, communicating or noncommunicating additional lumen etc.etc:
>
>
>
> Transection of proximal distal thoracicaorta adjacent to the isthmus.
>
> ________________________________
>
>
>
>
> Left, aortic dissection with intimal flapand entry site of distal thoracic aorta;
> Right, aortic dissectionrenal flow via color flow Doppler through intimal tear.
> TL,true lumen; FL, false lumen.
>
>
> ________________________________
>
>
>
> Ivan Hronek MD
> Los Angeles, CA
> http://health.groups.yahoo.com/group/Anesthideas/
>
> "We are what we repeatedly do. Excellence, then, is not an act, but a habit." Aristotle
> PPlease don't print this e-mail unless you really need to.
>
> ________________________________
>
> Confidentiality Notice: This transmission and any attached documents may be confidential and contain information protected by State and Federal Medical Privacy statutes and is legally privileged. They are intended for use only by the addressee. If you are not the intended recipient of this transmission, or an agent of the intended recipient, you are prohibited from reading, disclosing, printing, saving, copying, using, or otherwise disseminating any information contained in this transmission. If you received this transmission in error, please accept our apologies and notify me at ivanhronek at yahoo.comand delete the entire message and its attachments. Thank you. Disclaimer: this message contains the personal views of the author. The author will not be responsible in any way for procedures or approaches perfomed in the way suggested in this note.
> ________________________________
>
>
>
>
> ----- Original Message ----
> From: Ian Seppelt
> To: "Trauma & Critical Care mailing list" ; ivanhronek at yahoo.com
> Sent: Thursday, May 1, 2008 5:04:18 PM
> Subject: Re: unusual case
>
> Ascending aorta DISSECTION is not a traumatic injury, and is totally
> unrelated pathologically to traumatic aortic RUPTURE which is most
> commonly seen at the level of the ligamentum arteroisum / left
> subclavian artery.
>
> Ian
>
> correspondence to: seppelt at med.usyd.edu.au
>
> Ian Seppelt FANZCA FJFICM
> Senior Staff Specialist
> Dept of Intensive Care Medicine
> The Nepean Hospital, PO Box 63 Penrith NSW 2751
> Director of Clinical Research, Sydney West AHS
> Clinical Lecturer, University of Sydney
>
>>>> ivanhronek at yahoo.com 05/02/08 4:47 am>>>
> We recently had a small plane pilot crash victim allergic to iodine and
> so assessed the aorta with TEE.
> Typical ascending aorta dissections are relatively easy to diagnose
> with a visible flap and a second lumen with flow.
> Commonly there is also AI and pericardial effusion accompanying. Arch
> is not visible on TEE due to the left mainstem bronchus interposition.
> Descending aorta is nicely visible on long and short axis ("tube" and
> "salami" cuts), typical site transsections are accessible. One can also
> see AIH - aortic intramural hematomas - no flow in the accessory lumen.
> There are VOMITs possible - the arch cen have a reverberation artifact
> which looks like a second lumen. Also, which happened in our case, there
> is the left innominate vein which normally adheres to the arch and has
> flow in the opposite direction, which can be pulsatile so close to the
> right heart, especially with e.g. TR. It too can mimic a dissection.
> Ivan Hronek MD
> Los Angeles, CA
> http://health.groups.yahoo.com/group/Anesthideas/
>
> "We are what we repeatedly do. Excellence, then, is not an act, but a
> habit." Aristotle
> PPlease don't print this e-mail unless you really need to.
>
> ________________________________
>
> Confidentiality Notice: This transmission and any attached documents
> may be confidential and contain information protected by State and
> Federal Medical Privacy statutes and is legally privileged. They are
> intended for use only by the addressee. If you are not the intended
> recipient of this transmission, or an agent of the intended recipient,
> you are prohibited from reading, disclosing, printing, saving, copying,
> using, or otherwise disseminating any information contained in this
> transmission. If you received this transmission in error, please accept
> our apologies and notify me at ivanhronek at yahoo.comand delete the
> entire message and its attachments. Thank you. Disclaimer: this message
> contains the personal views of the author. The author will not be
> responsible in any way for procedures or approaches perfomed in the way
> suggested in this note.
> ________________________________
>
>
>
>
> ----- Original Message ----
> From: jduchesne1
> To: "Trauma & Critical Care mailing list"
> Sent: Thursday, May 1, 2008 10:38:35 AM
> Subject: Re: unusual case
>
> It is really hard to see the ct Ao injury which I think that is what
> you r trying to point out. In the event of a true (not a VOMIT) Ao
> injury with combine TBI, non operative management with control of
> patient delta P/delta T with breviblock is indicated. On the other hand
> special attention needs to be taken for good ICP/CPP readings in order
> to prevent secondary brain injury. Good judgment and close ICU care is a
> most.
> Please send more cuts of the CT.
> Always remember communication is of the essence among physicians in
> polytrauma patients.
> Good case.
> Juan
> CharityOne
> Sent via BlackBerry by AT&T
>
> -----Original Message-----
> From: Tchaka Shepherd
>
> Date: Thu, 1 May 2008 10:09:29
> To:"Trauma & Critical Care mailing list"
> Subject: RE: unusual case
>
>
>
> Can you send more images of the CTA?
>
>
>
>
> ----------------------------------------
>> To: trauma-list at trauma.org
>> From: nappio at aol.com
>> Date: Thu, 1 May 2008 16:50:34 +0000
>> Subject: Re: unusual case
>>
>> CHI and c spine injury. What is unusual?
>> Sent from my Verizon Wireless BlackBerry
>>
>> -----Original Message-----
>> From: "Michael Stein M.D."
>>
>> Date: Thu, 1 May 2008 19:37:42
>> To:"'Trauma & Critical Care mailing list'"
>> Subject: RE: unusual case
>>
>>
>> Not enough cuts from the CTA but...
>> If Neuro don't want him STAT in the OR, perform FORMAL Arch + 4
> vessel
>> Angiography and go on from there.
>> Mickey
>>
>> -----Original Message-----
>> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org]
>> On Behalf Of daniel simon
>> Sent: Thursday, May 01, 2008 6:29 PM
>> To: trauma-list at trauma.org
>> Subject: unusual case
>>
>> 43 year old motorcycle crash victim , on scene intubation for GCS of
> 5. On
>> admission intubated and ventilated, B.P 130/80 P 82 sat 100% , GCS 7
> (T) .
>> PE: skin lacerations and central hematoma anterior neck - zone 1.
>> Head CT - SAH, Frontal contusions,small Frontal SDH, many skull
> fractures.
>> C-spine: fracture of C1
>> Chest XR and relevant cuts from the chest CTA included.
>> Abdominal CT normal
>> What would you do now?
>>
>> --
>> trauma-list : TRAUMA.ORG
>> To change your settings or unsubscribe visit:
>> http://www.trauma.org/index.php?/community/
>
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> ______________________________________________________________________________
>
> This electronic message and any attachments may be confidential. If you
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