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A T`U:F9$%T[N V5l25ɋ!`LdtyvW3wPaH\ՠNꝁǸR@ڃ1$dMÅhABek=ҾIk#noM ?jEN*  =er^C#\ֹ.o@)"vW+moo%ͅAc{4 rmAqhmKEOA#mr\\2!{ia66wkeh%8f8E!kՊr`hxi W0% 4(._At kw<{ t-khG:"+ZWȃ1^Kc 1]\>6>0kq vymmw5qJs Nq5WZ&N`$v5aA]:5G8 :rْ~Pe6Irƈ8 gqPe/̃ol" PGcIڃVܹ 1۶Aa֘An̨_MkXk\CPݾ#)hz2n |{̃"͸`њ@[:b Y9H8f SyPb9ZJ$ $ (:v1 %q[EYFw1H|9yeƒymV!ǀ<4|xnZlA<<ԁ,;x(::uZ0Bwe䍸tws n\޸e&0ߘQ^n쥹ĩH'02f4U0i@I0 Gc13˸`X1+Jܤb̃Wsug>u$P]ÃlB8I~]1H5~J ~R ~J ~B ~B ~B ~B ~B ~1t۠@~Ӡat ?NkD ~@?hD?hD a4 ?FHG7gb  endstream endobj 38 0 obj<>stream JFIFddDucky<Adobed       h  !1AQaq"S2r5R#3dBbs4%C ?=cEA]k䵱B"l\ G ? 1\Mu@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@A%尻,ϮC9O#c 8ҙil<(6bsu}_5fz8j eoREIz(:Cx^h5q"fߵRM#mvcD.iXfaZPjErK՝sxPtGHiN摈ߍP& 2Vřr jڇrhW0e%u,6;Mwe=ڕFco 89 +[ ˺Hhvv baIp AxquihaCLW dզV-r2ͷᅤTеߺZA\0c fv9=r.!tnwM55ʁ4d=ҁ\v׺I9^^N`MMj|76sNԸRcĂ;=JQ!jB =vL[a<|.<@bP]G\ZL5Ѳ.V᷌KZbvjէx(5w5qn_5mw&\ސl]3F*4m'705񼲣֐G9O }uE58ɘ Alrr蝃[ƂZ8v//pF(,N&8p(0HbPre.`yvVP]A{ԶbB qRdhz"k9v@zֆPcǕiCM8]Jyq 3P@" 0P1dM x%­ڃ ӬmkpuZj 08Ew_3TS&ֿ[dpv F e6 >_ %%y x\ړJ6 - pރc#94;)Nd8 08֧Z΃P@iliq9}2x4Qߎ PҔxj>t6PcPK!ή&A66676@@@AQT@7 -O VhsO -+psCj* reͼ1+\Mu@@@@@@@@@@@@Ak&Y0(9Aj7=v"&y=Sb:/Ұb`̃˦t6sZoނ‚׳^X{$ Ԑ)ʂv3q,hiw u@@@@@@@@@@@A9`l2&.cN*jM !”y(-7̃o-+k: 3 9\文pW+I#r23RwaʂȀ;Z6atXx8J}\]dH{Z5{ 6|: tOM|,ֿ7̃u23Xb}v)CiˉA.~ @@A\-5mwm9ܾ!# ƣ:g; l&??TyDjQglm*0!)'2 =E7̃iolf7: QkiX1''#}{oo CQ,=ރ҂>+Hu2O xf6:MqPrs?A<|V o|*!^Ak}rm ]\퍑Av@AR@ߔYlYeNk̂Roȿ DxcO 6,tNX %Λz ;PZ/oPЃIe& ;x!/lqnA$}t Ì1̃X}|,#G\ػ 98is Zjb~4y" 4zٝ <P #iFA,5kZ(ր*z]1;p-6q %ծ#5k-_x!n h`9 1AS$oZ-NjokEQ4rc"`i  ăc@8xq&bn1$g3 h Xjq9(l"wcDb&cWH4bI(:Ni OWAH~׺P[PTu7Z޿yv" vۻF<@86k-w7`AQO [q"<1TާXymfV0#c[\e#fj{\ݿ*u͸kre.Pqn.Y@joIm'Y ۘ%PIZJX "!? 2ͥZÕ ݗtc[*O5 :2^NC4ZfPFC:v3!q'ɂ tۦkjsv8{O Dq!{:#j [=+G64\œ#%ܒ$? YYۆ1"XX(YCҪ 5M*;f`mpx{Pc&HA~oܤIp+OJ$̃'cXրִP g'V^jQ^ѧhZ;sRA|lDBʺUAr#d+jӓeD \rV]Db fZJd;Z*8 -^;G`ԏ H[A' sAsxnidt]f{\roA%gm{k$l4P w5AܵPi<ͬl7AAxJ#W?{2jruͳZX ׷oҁ-;h(Ӷoҁ-;x(Ӷoҁ-;h(Ӷoҁ{h{hޭf{CAo3߶g;տlh w~ٞ@V==ߵg;Ϳjh w~՞@0vyg;=`Yjh w;V{Aڳ՞@0vyg;==|y_hp|y_hp=|y uv|y_hp7 uv|y_hp=t=y Tbƒ(*'Aۭi3Shu): Yo3֒Ho14A#^VO pK&lZfټ| s^KeڃV##h@1PeI$[W&%7 dcj*^3 2\^X*A6(g)ix? A T`U:F9$%T[N V5l25ɋ!`LdtyvW3wPaH\ՠNꝁǸR@ڃ1$dMÅhABek=ҾIk#noM ?jEN*  =er^C#\ֹ.o@)"vW+moo%ͅAc{4 rmAqhmKEOA#mr\\2!{ia66wkeh%8f8E!kՊr`hxi W0% 4(._At kw<{ t-khG:"+ZWȃ1^Kc 1]\>6>0kq vymmw5qJs Nq5WZ&N`$v5aA]:5G8 :rْ~Pe6Irƈ8 gqPe/̃ol" PGcIڃVܹ 1۶Aa֘An̨_MkXk\CPݾ#)hz2n |{̃"͸`њ@[:b Y9H8f SyPb9ZJ$ $ (:v1 %q[EYFw1H|9yeƒymV!ǀ<4|xnZlA<<ԁ,;x(::uZ0Bwe䍸tws n\޸e&0ߘQ^n쥹ĩH'02f4U0i@I0 Gc13˸`X1+Jܤb̃Wsug>u$P]ÃlB8I~]1H5~J ~R ~J ~B ~B ~B ~B ~B ~1t۠@~Ӡat ?NkD ~@?hD?hD a4 ?FHG7gb  endstream endobj 41 0 obj<>stream JFIFddDucky<Adobed       h  !1AQaq"S2r5R#3dBbs4%C ?=cEA]k䵱B"l\ G ? 1\Mu@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@A%尻,ϮC9O#c 8ҙil<(6bsu}_5fz8j eoREIz(:Cx^h5q"fߵRM#mvcD.iXfaZPjErK՝sxPtGHiN摈ߍP& 2Vřr jڇrhW0e%u,6;Mwe=ڕFco 89 +[ ˺Hhvv baIp AxquihaCLW dզV-r2ͷᅤTеߺZA\0c fv9=r.!tnwM55ʁ4d=ҁ\v׺I9^^N`MMj|76sNԸRcĂ;=JQ!jB =vL[a<|.<@bP]G\ZL5Ѳ.V᷌KZbvjէx(5w5qn_5mw&\ސl]3F*4m'705񼲣֐G9O }uE58ɘ Alrr蝃[ƂZ8v//pF(,N&8p(0HbPre.`yvVP]A{ԶbB qRdhz"k9v@zֆPcǕiCM8]Jyq 3P@" 0P1dM x%­ڃ ӬmkpuZj 08Ew_3TS&ֿ[dpv F e6 >_ %%y x\ړJ6 - pރc#94;)Nd8 08֧Z΃P@iliq9}2x4Qߎ PҔxj>t6PcPK!ή&A66676@@@AQT@7 -O VhsO -+psCj* reͼ1+\Mu@@@@@@@@@@@@Ak&Y0(9Aj7=v"&y=Sb:/Ұb`̃˦t6sZoނ‚׳^X{$ Ԑ)ʂv3q,hiw u@@@@@@@@@@@A9`l2&.cN*jM !”y(-7̃o-+k: 3 9\文pW+I#r23RwaʂȀ;Z6atXx8J}\]dH{Z5{ 6|: tOM|,ֿ7̃u23Xb}v)CiˉA.~ @@A\-5mwm9ܾ!# ƣ:g; l&??TyDjQglm*0!)'2 =E7̃iolf7: QkiX1''#}{oo CQ,=ރ҂>+Hu2O xf6:MqPrs?A<|V o|*!^Ak}rm ]\퍑Av@AR@ߔYlYeNk̂Roȿ DxcO 6,tNX %Λz ;PZ/oPЃIe& ;x!/lqnA$}t Ì1̃X}|,#G\ػ 98is Zjb~4y" 4zٝ <P #iFA,5kZ(ր*z]1;p-6q %ծ#5k-_x!n h`9 1AS$oZ-NjokEQ4rc"`i  ăc@8xq&bn1$g3 h Xjq9(l"wcDb&cWH4bI(:Ni OWAH~׺P[PTu7Z޿yv" vۻF<@86k-w7`AQO [q"<1TާXymfV0#c[\e#fj{\ݿ*u͸kre.Pqn.Y@joIm'Y ۘ%PIZJX "!? 2ͥZÕ ݗtc[*O5 :2^NC4ZfPFC:v3!q'ɂ tۦkjsv8{O Dq!{:#j [=+G64\œ#%ܒ$? YYۆ1"XX(YCҪ 5M*;f`mpx{Pc&HA~oܤIp+OJ$̃'cXրִP g'V^jQ^ѧhZ;sRA|lDBʺUAr#d+jӓeD \rV]Db fZJd;Z*8 -^;G`ԏ H[A' sAsxnidt]f{\roA%gm{k$l4P w5AܵPi<ͬl7AAxJ#W?{2jruͳZX ׷oҁ-;h(Ӷoҁ-;x(Ӷoҁ-;h(Ӷoҁ{h{hޭf{CAo3߶g;տlh w~ٞ@V==ߵg;Ϳjh w~՞@0vyg;=`Yjh w;V{Aڳ՞@0vyg;==|y_hp|y_hp=|y uv|y_hp7 uv|y_hp=t=y Tbƒ(*'Aۭi3Shu): Yo3֒Ho14A#^VO pK&lZfټ| s^KeڃV##h@1PeI$[W&%7 dcj*^3 2\^X*A6(g)ix? A T`U:F9$%T[N V5l25ɋ!`LdtyvW3wPaH\ՠNꝁǸR@ڃ1$dMÅhABek=ҾIk#noM ?jEN*  =er^C#\ֹ.o@)"vW+moo%ͅAc{4 rmAqhmKEOA#mr\\2!{ia66wkeh%8f8E!kՊr`hxi W0% 4(._At kw<{ t-khG:"+ZWȃ1^Kc 1]\>6>0kq vymmw5qJs Nq5WZ&N`$v5aA]:5G8 :rْ~Pe6Irƈ8 gqPe/̃ol" PGcIڃVܹ 1۶Aa֘An̨_MkXk\CPݾ#)hz2n |{̃"͸`њ@[:b Y9H8f SyPb9ZJ$ $ (:v1 %q[EYFw1H|9yeƒymV!ǀ<4|xnZlA<<ԁ,;x(::uZ0Bwe䍸tws n\޸e&0ߘQ^n쥹ĩH'02f4U0i@I0 Gc13˸`X1+Jܤb̃Wsug>u$P]ÃlB8I~]1H5~J ~R ~J ~B ~B ~B ~B ~B ~1t۠@~Ӡat ?NkD ~@?hD?hD a4 ?FHG7gb  endstream endobj 44 0 obj<>stream JFIFddDucky<Adobed       h  !1AQaq"S2r5R#3dBbs4%C ?=cEA]k䵱B"l\ G ? 1\Mu@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@A%尻,ϮC9O#c 8ҙil<(6bsu}_5fz8j eoREIz(:Cx^h5q"fߵRM#mvcD.iXfaZPjErK՝sxPtGHiN摈ߍP& 2Vřr jڇrhW0e%u,6;Mwe=ڕFco 89 +[ ˺Hhvv baIp AxquihaCLW dզV-r2ͷᅤTеߺZA\0c fv9=r.!tnwM55ʁ4d=ҁ\v׺I9^^N`MMj|76sNԸRcĂ;=JQ!jB =vL[a<|.<@bP]G\ZL5Ѳ.V᷌KZbvjէx(5w5qn_5mw&\ސl]3F*4m'705񼲣֐G9O }uE58ɘ Alrr蝃[ƂZ8v//pF(,N&8p(0HbPre.`yvVP]A{ԶbB qRdhz"k9v@zֆPcǕiCM8]Jyq 3P@" 0P1dM x%­ڃ ӬmkpuZj 08Ew_3TS&ֿ[dpv F e6 >_ %%y x\ړJ6 - pރc#94;)Nd8 08֧Z΃P@iliq9}2x4Qߎ PҔxj>t6PcPK!ή&A66676@@@AQT@7 -O VhsO -+psCj* reͼ1+\Mu@@@@@@@@@@@@Ak&Y0(9Aj7=v"&y=Sb:/Ұb`̃˦t6sZoނ‚׳^X{$ Ԑ)ʂv3q,hiw u@@@@@@@@@@@A9`l2&.cN*jM !”y(-7̃o-+k: 3 9\文pW+I#r23RwaʂȀ;Z6atXx8J}\]dH{Z5{ 6|: tOM|,ֿ7̃u23Xb}v)CiˉA.~ @@A\-5mwm9ܾ!# ƣ:g; l&??TyDjQglm*0!)'2 =E7̃iolf7: QkiX1''#}{oo CQ,=ރ҂>+Hu2O xf6:MqPrs?A<|V o|*!^Ak}rm ]\퍑Av@AR@ߔYlYeNk̂Roȿ DxcO 6,tNX %Λz ;PZ/oPЃIe& ;x!/lqnA$}t Ì1̃X}|,#G\ػ 98is Zjb~4y" 4zٝ <P #iFA,5kZ(ր*z]1;p-6q %ծ#5k-_x!n h`9 1AS$oZ-NjokEQ4rc"`i  ăc@8xq&bn1$g3 h Xjq9(l"wcDb&cWH4bI(:Ni OWAH~׺P[PTu7Z޿yv" vۻF<@86k-w7`AQO [q"<1TާXymfV0#c[\e#fj{\ݿ*u͸kre.Pqn.Y@joIm'Y ۘ%PIZJX "!? 2ͥZÕ ݗtc[*O5 :2^NC4ZfPFC:v3!q'ɂ tۦkjsv8{O Dq!{:#j [=+G64\œ#%ܒ$? YYۆ1"XX(YCҪ 5M*;f`mpx{Pc&HA~oܤIp+OJ$̃'cXրִP g'V^jQ^ѧhZ;sRA|lDBʺUAr#d+jӓeD \rV]Db fZJd;Z*8 -^;G`ԏ H[A' sAsxnidt]f{\roA%gm{k$l4P w5AܵPi<ͬl7AAxJ#W?{2jruͳZX ׷oҁ-;h(Ӷoҁ-;x(Ӷoҁ-;h(Ӷoҁ{h{hޭf{CAo3߶g;տlh w~ٞ@V==ߵg;Ϳjh w~՞@0vyg;=`Yjh w;V{Aڳ՞@0vyg;==|y_hp|y_hp=|y uv|y_hp7 uv|y_hp=t=y Tbƒ(*'Aۭi3Shu): Yo3֒Ho14A#^VO pK&lZfټ| s^KeڃV##h@1PeI$[W&%7 dcj*^3 2\^X*A6(g)ix? A T`U:F9$%T[N V5l25ɋ!`LdtyvW3wPaH\ՠNꝁǸR@ڃ1$dMÅhABek=ҾIk#noM ?jEN*  =er^C#\ֹ.o@)"vW+moo%ͅAc{4 rmAqhmKEOA#mr\\2!{ia66wkeh%8f8E!kՊr`hxi W0% 4(._At kw<{ t-khG:"+ZWȃ1^Kc 1]\>6>0kq vymmw5qJs Nq5WZ&N`$v5aA]:5G8 :rْ~Pe6Irƈ8 gqPe/̃ol" PGcIڃVܹ 1۶Aa֘An̨_MkXk\CPݾ#)hz2n |{̃"͸`њ@[:b Y9H8f SyPb9ZJ$ $ (:v1 %q[EYFw1H|9yeƒymV!ǀ<4|xnZlA<<ԁ,;x(::uZ0Bwe䍸tws n\޸e&0ߘQ^n쥹ĩH'02f4U0i@I0 Gc13˸`X1+Jܤb̃Wsug>u$P]ÃlB8I~]1H5~J ~R ~J ~B ~B ~B ~B ~B ~1t۠@~Ӡat ?NkD ~@?hD?hD a4 ?FHG7gb  endstream endobj 47 0 obj<>stream JFIFddDucky<Adobed       h  !1AQaq"S2r5R#3dBbs4%C ?=cEA]k䵱B"l\ G ? 1\Mu@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@A%尻,ϮC9O#c 8ҙil<(6bsu}_5fz8j eoREIz(:Cx^h5q"fߵRM#mvcD.iXfaZPjErK՝sxPtGHiN摈ߍP& 2Vřr jڇrhW0e%u,6;Mwe=ڕFco 89 +[ ˺Hhvv baIp AxquihaCLW dզV-r2ͷᅤTеߺZA\0c fv9=r.!tnwM55ʁ4d=ҁ\v׺I9^^N`MMj|76sNԸRcĂ;=JQ!jB =vL[a<|.<@bP]G\ZL5Ѳ.V᷌KZbvjէx(5w5qn_5mw&\ސl]3F*4m'705񼲣֐G9O }uE58ɘ Alrr蝃[ƂZ8v//pF(,N&8p(0HbPre.`yvVP]A{ԶbB qRdhz"k9v@zֆPcǕiCM8]Jyq 3P@" 0P1dM x%­ڃ ӬmkpuZj 08Ew_3TS&ֿ[dpv F e6 >_ %%y x\ړJ6 - pރc#94;)Nd8 08֧Z΃P@iliq9}2x4Qߎ PҔxj>t6PcPK!ή&A66676@@@AQT@7 -O VhsO -+psCj* reͼ1+\Mu@@@@@@@@@@@@Ak&Y0(9Aj7=v"&y=Sb:/Ұb`̃˦t6sZoނ‚׳^X{$ Ԑ)ʂv3q,hiw u@@@@@@@@@@@A9`l2&.cN*jM !”y(-7̃o-+k: 3 9\文pW+I#r23RwaʂȀ;Z6atXx8J}\]dH{Z5{ 6|: tOM|,ֿ7̃u23Xb}v)CiˉA.~ @@A\-5mwm9ܾ!# ƣ:g; l&??TyDjQglm*0!)'2 =E7̃iolf7: QkiX1''#}{oo CQ,=ރ҂>+Hu2O xf6:MqPrs?A<|V o|*!^Ak}rm ]\퍑Av@AR@ߔYlYeNk̂Roȿ DxcO 6,tNX %Λz ;PZ/oPЃIe& ;x!/lqnA$}t Ì1̃X}|,#G\ػ 98is Zjb~4y" 4zٝ <P #iFA,5kZ(ր*z]1;p-6q %ծ#5k-_x!n h`9 1AS$oZ-NjokEQ4rc"`i  ăc@8xq&bn1$g3 h Xjq9(l"wcDb&cWH4bI(:Ni OWAH~׺P[PTu7Z޿yv" vۻF<@86k-w7`AQO [q"<1TާXymfV0#c[\e#fj{\ݿ*u͸kre.Pqn.Y@joIm'Y ۘ%PIZJX "!? 2ͥZÕ ݗtc[*O5 :2^NC4ZfPFC:v3!q'ɂ tۦkjsv8{O Dq!{:#j [=+G64\œ#%ܒ$? YYۆ1"XX(YCҪ 5M*;f`mpx{Pc&HA~oܤIp+OJ$̃'cXրִP g'V^jQ^ѧhZ;sRA|lDBʺUAr#d+jӓeD \rV]Db fZJd;Z*8 -^;G`ԏ H[A' sAsxnidt]f{\roA%gm{k$l4P w5AܵPi<ͬl7AAxJ#W?{2jruͳZX ׷oҁ-;h(Ӷoҁ-;x(Ӷoҁ-;h(Ӷoҁ{h{hޭf{CAo3߶g;տlh w~ٞ@V==ߵg;Ϳjh w~՞@0vyg;=`Yjh w;V{Aڳ՞@0vyg;==|y_hp|y_hp=|y uv|y_hp7 uv|y_hp=t=y Tbƒ(*'Aۭi3Shu): Yo3֒Ho14A#^VO pK&lZfټ| s^KeڃV##h@1PeI$[W&%7 dcj*^3 2\^X*A6(g)ix? A T`U:F9$%T[N V5l25ɋ!`LdtyvW3wPaH\ՠNꝁǸR@ڃ1$dMÅhABek=ҾIk#noM ?jEN*  =er^C#\ֹ.o@)"vW+moo%ͅAc{4 rmAqhmKEOA#mr\\2!{ia66wkeh%8f8E!kՊr`hxi W0% 4(._At kw<{ t-khG:"+ZWȃ1^Kc 1]\>6>0kq vymmw5qJs Nq5WZ&N`$v5aA]:5G8 :rْ~Pe6Irƈ8 gqPe/̃ol" PGcIڃVܹ 1۶Aa֘An̨_MkXk\CPݾ#)hz2n |{̃"͸`њ@[:b Y9H8f SyPb9ZJ$ $ (:v1 %q[EYFw1H|9yeƒymV!ǀ<4|xnZlA<<ԁ,;x(::uZ0Bwe䍸tws n\޸e&0ߘQ^n쥹ĩH'02f4U0i@I0 Gc13˸`X1+Jܤb̃Wsug>u$P]ÃlB8I~]1H5~J ~R ~J ~B ~B ~B ~B ~B ~1t۠@~Ӡat ?NkD ~@?hD?hD a4 ?FHG7gb  endstream endobj 50 0 obj<>stream JFIFddDucky<Adobed       h  !1AQaq"S2r5R#3dBbs4%C ?=cEA]k䵱B"l\ G ? 1\Mu@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@A%尻,ϮC9O#c 8ҙil<(6bsu}_5fz8j eoREIz(:Cx^h5q"fߵRM#mvcD.iXfaZPjErK՝sxPtGHiN摈ߍP& 2Vřr jڇrhW0e%u,6;Mwe=ڕFco 89 +[ ˺Hhvv baIp AxquihaCLW dզV-r2ͷᅤTеߺZA\0c fv9=r.!tnwM55ʁ4d=ҁ\v׺I9^^N`MMj|76sNԸRcĂ;=JQ!jB =vL[a<|.<@bP]G\ZL5Ѳ.V᷌KZbvjէx(5w5qn_5mw&\ސl]3F*4m'705񼲣֐G9O }uE58ɘ Alrr蝃[ƂZ8v//pF(,N&8p(0HbPre.`yvVP]A{ԶbB qRdhz"k9v@zֆPcǕiCM8]Jyq 3P@" 0P1dM x%­ڃ ӬmkpuZj 08Ew_3TS&ֿ[dpv F e6 >_ %%y x\ړJ6 - pރc#94;)Nd8 08֧Z΃P@iliq9}2x4Qߎ PҔxj>t6PcPK!ή&A66676@@@AQT@7 -O VhsO -+psCj* reͼ1+\Mu@@@@@@@@@@@@Ak&Y0(9Aj7=v"&y=Sb:/Ұb`̃˦t6sZoނ‚׳^X{$ Ԑ)ʂv3q,hiw u@@@@@@@@@@@A9`l2&.cN*jM !”y(-7̃o-+k: 3 9\文pW+I#r23RwaʂȀ;Z6atXx8J}\]dH{Z5{ 6|: tOM|,ֿ7̃u23Xb}v)CiˉA.~ @@A\-5mwm9ܾ!# ƣ:g; l&??TyDjQglm*0!)'2 =E7̃iolf7: QkiX1''#}{oo CQ,=ރ҂>+Hu2O xf6:MqPrs?A<|V o|*!^Ak}rm ]\퍑Av@AR@ߔYlYeNk̂Roȿ DxcO 6,tNX %Λz ;PZ/oPЃIe& ;x!/lqnA$}t Ì1̃X}|,#G\ػ 98is Zjb~4y" 4zٝ <P #iFA,5kZ(ր*z]1;p-6q %ծ#5k-_x!n h`9 1AS$oZ-NjokEQ4rc"`i  ăc@8xq&bn1$g3 h Xjq9(l"wcDb&cWH4bI(:Ni OWAH~׺P[PTu7Z޿yv" vۻF<@86k-w7`AQO [q"<1TާXymfV0#c[\e#fj{\ݿ*u͸kre.Pqn.Y@joIm'Y ۘ%PIZJX "!? 2ͥZÕ ݗtc[*O5 :2^NC4ZfPFC:v3!q'ɂ tۦkjsv8{O Dq!{:#j [=+G64\œ#%ܒ$? YYۆ1"XX(YCҪ 5M*;f`mpx{Pc&HA~oܤIp+OJ$̃'cXրִP g'V^jQ^ѧhZ;sRA|lDBʺUAr#d+jӓeD \rV]Db fZJd;Z*8 -^;G`ԏ H[A' sAsxnidt]f{\roA%gm{k$l4P w5AܵPi<ͬl7AAxJ#W?{2jruͳZX ׷oҁ-;h(Ӷoҁ-;x(Ӷoҁ-;h(Ӷoҁ{h{hޭf{CAo3߶g;տlh w~ٞ@V==ߵg;Ϳjh w~՞@0vyg;=`Yjh w;V{Aڳ՞@0vyg;==|y_hp|y_hp=|y uv|y_hp7 uv|y_hp=t=y Tbƒ(*'Aۭi3Shu): Yo3֒Ho14A#^VO pK&lZfټ| s^KeڃV##h@1PeI$[W&%7 dcj*^3 2\^X*A6(g)ix? A T`U:F9$%T[N V5l25ɋ!`LdtyvW3wPaH\ՠNꝁǸR@ڃ1$dMÅhABek=ҾIk#noM ?jEN*  =er^C#\ֹ.o@)"vW+moo%ͅAc{4 rmAqhmKEOA#mr\\2!{ia66wkeh%8f8E!kՊr`hxi W0% 4(._At kw<{ t-khG:"+ZWȃ1^Kc 1]\>6>0kq vymmw5qJs Nq5WZ&N`$v5aA]:5G8 :rْ~Pe6Irƈ8 gqPe/̃ol" PGcIڃVܹ 1۶Aa֘An̨_MkXk\CPݾ#)hz2n |{̃"͸`њ@[:b Y9H8f SyPb9ZJ$ $ (:v1 %q[EYFw1H|9yeƒymV!ǀ<4|xnZlA<<ԁ,;x(::uZ0Bwe䍸tws n\޸e&0ߘQ^n쥹ĩH'02f4U0i@I0 Gc13˸`X1+Jܤb̃Wsug>u$P]ÃlB8I~]1H5~J ~R ~J ~B ~B ~B ~B ~B ~1t۠@~Ӡat ?NkD ~@?hD?hD a4 ?FHG7gb  endstream endobj 53 0 obj<>stream JFIFddDucky<Adobed       h  !1AQaq"S2r5R#3dBbs4%C ?=cEA]k䵱B"l\ G ? 1\Mu@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@A%尻,ϮC9O#c 8ҙil<(6bsu}_5fz8j eoREIz(:Cx^h5q"fߵRM#mvcD.iXfaZPjErK՝sxPtGHiN摈ߍP& 2Vřr jڇrhW0e%u,6;Mwe=ڕFco 89 +[ ˺Hhvv baIp AxquihaCLW dզV-r2ͷᅤTеߺZA\0c fv9=r.!tnwM55ʁ4d=ҁ\v׺I9^^N`MMj|76sNԸRcĂ;=JQ!jB =vL[a<|.<@bP]G\ZL5Ѳ.V᷌KZbvjէx(5w5qn_5mw&\ސl]3F*4m'705񼲣֐G9O }uE58ɘ Alrr蝃[ƂZ8v//pF(,N&8p(0HbPre.`yvVP]A{ԶbB qRdhz"k9v@zֆPcǕiCM8]Jyq 3P@" 0P1dM x%­ڃ ӬmkpuZj 08Ew_3TS&ֿ[dpv F e6 >_ %%y x\ړJ6 - pރc#94;)Nd8 08֧Z΃P@iliq9}2x4Qߎ PҔxj>t6PcPK!ή&A66676@@@AQT@7 -O VhsO -+psCj* reͼ1+\Mu@@@@@@@@@@@@Ak&Y0(9Aj7=v"&y=Sb:/Ұb`̃˦t6sZoނ‚׳^X{$ Ԑ)ʂv3q,hiw u@@@@@@@@@@@A9`l2&.cN*jM !”y(-7̃o-+k: 3 9\文pW+I#r23RwaʂȀ;Z6atXx8J}\]dH{Z5{ 6|: tOM|,ֿ7̃u23Xb}v)CiˉA.~ @@A\-5mwm9ܾ!# ƣ:g; l&??TyDjQglm*0!)'2 =E7̃iolf7: QkiX1''#}{oo CQ,=ރ҂>+Hu2O xf6:MqPrs?A<|V o|*!^Ak}rm ]\퍑Av@AR@ߔYlYeNk̂Roȿ DxcO 6,tNX %Λz ;PZ/oPЃIe& ;x!/lqnA$}t Ì1̃X}|,#G\ػ 98is Zjb~4y" 4zٝ <P #iFA,5kZ(ր*z]1;p-6q %ծ#5k-_x!n h`9 1AS$oZ-NjokEQ4rc"`i  ăc@8xq&bn1$g3 h Xjq9(l"wcDb&cWH4bI(:Ni OWAH~׺P[PTu7Z޿yv" vۻF<@86k-w7`AQO [q"<1TާXymfV0#c[\e#fj{\ݿ*u͸kre.Pqn.Y@joIm'Y ۘ%PIZJX "!? 2ͥZÕ ݗtc[*O5 :2^NC4ZfPFC:v3!q'ɂ tۦkjsv8{O Dq!{:#j [=+G64\œ#%ܒ$? YYۆ1"XX(YCҪ 5M*;f`mpx{Pc&HA~oܤIp+OJ$̃'cXրִP g'V^jQ^ѧhZ;sRA|lDBʺUAr#d+jӓeD \rV]Db fZJd;Z*8 -^;G`ԏ H[A' sAsxnidt]f{\roA%gm{k$l4P w5AܵPi<ͬl7AAxJ#W?{2jruͳZX ׷oҁ-;h(Ӷoҁ-;x(Ӷoҁ-;h(Ӷoҁ{h{hޭf{CAo3߶g;տlh w~ٞ@V==ߵg;Ϳjh w~՞@0vyg;=`Yjh w;V{Aڳ՞@0vyg;==|y_hp|y_hp=|y uv|y_hp7 uv|y_hp=t=y Tbƒ(*'Aۭi3Shu): Yo3֒Ho14A#^VO pK&lZfټ| s^KeڃV##h@1PeI$[W&%7 dcj*^3 2\^X*A6(g)ix? A T`U:F9$%T[N V5l25ɋ!`LdtyvW3wPaH\ՠNꝁǸR@ڃ1$dMÅhABek=ҾIk#noM ?jEN*  =er^C#\ֹ.o@)"vW+moo%ͅAc{4 rmAqhmKEOA#mr\\2!{ia66wkeh%8f8E!kՊr`hxi W0% 4(._At kw<{ t-khG:"+ZWȃ1^Kc 1]\>6>0kq vymmw5qJs Nq5WZ&N`$v5aA]:5G8 :rْ~Pe6Irƈ8 gqPe/̃ol" PGcIڃVܹ 1۶Aa֘An̨_MkXk\CPݾ#)hz2n |{̃"͸`њ@[:b Y9H8f SyPb9ZJ$ $ (:v1 %q[EYFw1H|9yeƒymV!ǀ<4|xnZlA<<ԁ,;x(::uZ0Bwe䍸tws n\޸e&0ߘQ^n쥹ĩH'02f4U0i@I0 Gc13˸`X1+Jܤb̃Wsug>u$P]ÃlB8I~]1H5~J ~R ~J ~B ~B ~B ~B ~B ~1t۠@~Ӡat ?NkD ~@?hD?hD a4 ?FHG7gb  endstream endobj 56 0 obj<>stream JFIFddDucky<Adobed       h  !1AQaq"S2r5R#3dBbs4%C ?=cEA]k䵱B"l\ G ? 1\Mu@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@A%尻,ϮC9O#c 8ҙil<(6bsu}_5fz8j eoREIz(:Cx^h5q"fߵRM#mvcD.iXfaZPjErK՝sxPtGHiN摈ߍP& 2Vřr jڇrhW0e%u,6;Mwe=ڕFco 89 +[ ˺Hhvv baIp AxquihaCLW dզV-r2ͷᅤTеߺZA\0c fv9=r.!tnwM55ʁ4d=ҁ\v׺I9^^N`MMj|76sNԸRcĂ;=JQ!jB =vL[a<|.<@bP]G\ZL5Ѳ.V᷌KZbvjէx(5w5qn_5mw&\ސl]3F*4m'705񼲣֐G9O }uE58ɘ Alrr蝃[ƂZ8v//pF(,N&8p(0HbPre.`yvVP]A{ԶbB qRdhz"k9v@zֆPcǕiCM8]Jyq 3P@" 0P1dM x%­ڃ ӬmkpuZj 08Ew_3TS&ֿ[dpv F e6 >_ %%y x\ړJ6 - pރc#94;)Nd8 08֧Z΃P@iliq9}2x4Qߎ PҔxj>t6PcPK!ή&A66676@@@AQT@7 -O VhsO -+psCj* reͼ1+\Mu@@@@@@@@@@@@Ak&Y0(9Aj7=v"&y=Sb:/Ұb`̃˦t6sZoނ‚׳^X{$ Ԑ)ʂv3q,hiw u@@@@@@@@@@@A9`l2&.cN*jM !”y(-7̃o-+k: 3 9\文pW+I#r23RwaʂȀ;Z6atXx8J}\]dH{Z5{ 6|: tOM|,ֿ7̃u23Xb}v)CiˉA.~ @@A\-5mwm9ܾ!# ƣ:g; l&??TyDjQglm*0!)'2 =E7̃iolf7: QkiX1''#}{oo CQ,=ރ҂>+Hu2O xf6:MqPrs?A<|V o|*!^Ak}rm ]\퍑Av@AR@ߔYlYeNk̂Roȿ DxcO 6,tNX %Λz ;PZ/oPЃIe& ;x!/lqnA$}t Ì1̃X}|,#G\ػ 98is Zjb~4y" 4zٝ <P #iFA,5kZ(ր*z]1;p-6q %ծ#5k-_x!n h`9 1AS$oZ-NjokEQ4rc"`i  ăc@8xq&bn1$g3 h Xjq9(l"wcDb&cWH4bI(:Ni OWAH~׺P[PTu7Z޿yv" vۻF<@86k-w7`AQO [q"<1TާXymfV0#c[\e#fj{\ݿ*u͸kre.Pqn.Y@joIm'Y ۘ%PIZJX "!? 2ͥZÕ ݗtc[*O5 :2^NC4ZfPFC:v3!q'ɂ tۦkjsv8{O Dq!{:#j [=+G64\œ#%ܒ$? YYۆ1"XX(YCҪ 5M*;f`mpx{Pc&HA~oܤIp+OJ$̃'cXրִP g'V^jQ^ѧhZ;sRA|lDBʺUAr#d+jӓeD \rV]Db fZJd;Z*8 -^;G`ԏ H[A' sAsxnidt]f{\roA%gm{k$l4P w5AܵPi<ͬl7AAxJ#W?{2jruͳZX ׷oҁ-;h(Ӷoҁ-;x(Ӷoҁ-;h(Ӷoҁ{h{hޭf{CAo3߶g;տlh w~ٞ@V==ߵg;Ϳjh w~՞@0vyg;=`Yjh w;V{Aڳ՞@0vyg;==|y_hp|y_hp=|y uv|y_hp7 uv|y_hp=t=y Tbƒ(*'Aۭi3Shu): Yo3֒Ho14A#^VO pK&lZfټ| s^KeڃV##h@1PeI$[W&%7 dcj*^3 2\^X*A6(g)ix? A T`U:F9$%T[N V5l25ɋ!`LdtyvW3wPaH\ՠNꝁǸR@ڃ1$dMÅhABek=ҾIk#noM ?jEN*  =er^C#\ֹ.o@)"vW+moo%ͅAc{4 rmAqhmKEOA#mr\\2!{ia66wkeh%8f8E!kՊr`hxi W0% 4(._At kw<{ t-khG:"+ZWȃ1^Kc 1]\>6>0kq vymmw5qJs Nq5WZ&N`$v5aA]:5G8 :rْ~Pe6Irƈ8 gqPe/̃ol" PGcIڃVܹ 1۶Aa֘An̨_MkXk\CPݾ#)hz2n |{̃"͸`њ@[:b Y9H8f SyPb9ZJ$ $ (:v1 %q[EYFw1H|9yeƒymV!ǀ<4|xnZlA<<ԁ,;x(::uZ0Bwe䍸tws n\޸e&0ߘQ^n쥹ĩH'02f4U0i@I0 Gc13˸`X1+Jܤb̃Wsug>u$P]ÃlB8I~]1H5~J ~R ~J ~B ~B ~B ~B ~B ~1t۠@~Ӡat ?NkD ~@?hD?hD a4 ?FHG7gb  endstream endobj 57 0 obj<> endobj 60 0 obj<>stream JFIFddDucky<Adobed       h  !1AQaq"S2r5R#3dBbs4%C ?=cEA]k䵱B"l\ G ? 1\Mu@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@A%尻,ϮC9O#c 8ҙil<(6bsu}_5fz8j eoREIz(:Cx^h5q"fߵRM#mvcD.iXfaZPjErK՝sxPtGHiN摈ߍP& 2Vřr jڇrhW0e%u,6;Mwe=ڕFco 89 +[ ˺Hhvv baIp AxquihaCLW dզV-r2ͷᅤTеߺZA\0c fv9=r.!tnwM55ʁ4d=ҁ\v׺I9^^N`MMj|76sNԸRcĂ;=JQ!jB =vL[a<|.<@bP]G\ZL5Ѳ.V᷌KZbvjէx(5w5qn_5mw&\ސl]3F*4m'705񼲣֐G9O }uE58ɘ Alrr蝃[ƂZ8v//pF(,N&8p(0HbPre.`yvVP]A{ԶbB qRdhz"k9v@zֆPcǕiCM8]Jyq 3P@" 0P1dM x%­ڃ ӬmkpuZj 08Ew_3TS&ֿ[dpv F e6 >_ %%y x\ړJ6 - pރc#94;)Nd8 08֧Z΃P@iliq9}2x4Qߎ PҔxj>t6PcPK!ή&A66676@@@AQT@7 -O VhsO -+psCj* reͼ1+\Mu@@@@@@@@@@@@Ak&Y0(9Aj7=v"&y=Sb:/Ұb`̃˦t6sZoނ‚׳^X{$ Ԑ)ʂv3q,hiw u@@@@@@@@@@@A9`l2&.cN*jM !”y(-7̃o-+k: 3 9\文pW+I#r23RwaʂȀ;Z6atXx8J}\]dH{Z5{ 6|: tOM|,ֿ7̃u23Xb}v)CiˉA.~ @@A\-5mwm9ܾ!# ƣ:g; l&??TyDjQglm*0!)'2 =E7̃iolf7: QkiX1''#}{oo CQ,=ރ҂>+Hu2O xf6:MqPrs?A<|V o|*!^Ak}rm ]\퍑Av@AR@ߔYlYeNk̂Roȿ DxcO 6,tNX %Λz ;PZ/oPЃIe& ;x!/lqnA$}t Ì1̃X}|,#G\ػ 98is Zjb~4y" 4zٝ <P #iFA,5kZ(ր*z]1;p-6q %ծ#5k-_x!n h`9 1AS$oZ-NjokEQ4rc"`i  ăc@8xq&bn1$g3 h Xjq9(l"wcDb&cWH4bI(:Ni OWAH~׺P[PTu7Z޿yv" vۻF<@86k-w7`AQO [q"<1TާXymfV0#c[\e#fj{\ݿ*u͸kre.Pqn.Y@joIm'Y ۘ%PIZJX "!? 2ͥZÕ ݗtc[*O5 :2^NC4ZfPFC:v3!q'ɂ tۦkjsv8{O Dq!{:#j [=+G64\œ#%ܒ$? YYۆ1"XX(YCҪ 5M*;f`mpx{Pc&HA~oܤIp+OJ$̃'cXրִP g'V^jQ^ѧhZ;sRA|lDBʺUAr#d+jӓeD \rV]Db fZJd;Z*8 -^;G`ԏ H[A' sAsxnidt]f{\roA%gm{k$l4P w5AܵPi<ͬl7AAxJ#W?{2jruͳZX ׷oҁ-;h(Ӷoҁ-;x(Ӷoҁ-;h(Ӷoҁ{h{hޭf{CAo3߶g;տlh w~ٞ@V==ߵg;Ϳjh w~՞@0vyg;=`Yjh w;V{Aڳ՞@0vyg;==|y_hp|y_hp=|y uv|y_hp7 uv|y_hp=t=y Tbƒ(*'Aۭi3Shu): Yo3֒Ho14A#^VO pK&lZfټ| s^KeڃV##h@1PeI$[W&%7 dcj*^3 2\^X*A6(g)ix? A T`U:F9$%T[N V5l25ɋ!`LdtyvW3wPaH\ՠNꝁǸR@ڃ1$dMÅhABek=ҾIk#noM ?jEN*  =er^C#\ֹ.o@)"vW+moo%ͅAc{4 rmAqhmKEOA#mr\\2!{ia66wkeh%8f8E!kՊr`hxi W0% 4(._At kw<{ t-khG:"+ZWȃ1^Kc 1]\>6>0kq vymmw5qJs Nq5WZ&N`$v5aA]:5G8 :rْ~Pe6Irƈ8 gqPe/̃ol" PGcIڃVܹ 1۶Aa֘An̨_MkXk\CPݾ#)hz2n |{̃"͸`њ@[:b Y9H8f SyPb9ZJ$ $ (:v1 %q[EYFw1H|9yeƒymV!ǀ<4|xnZlA<<ԁ,;x(::uZ0Bwe䍸tws n\޸e&0ߘQ^n쥹ĩH'02f4U0i@I0 Gc13˸`X1+Jܤb̃Wsug>u$P]ÃlB8I~]1H5~J ~R ~J ~B ~B ~B ~B ~B ~1t۠@~Ӡat ?NkD ~@?hD?hD a4 ?FHG7gb  endstream endobj 61 0 obj<> endobj 64 0 obj<>stream JFIFddDucky<Adobed       h  !1AQaq"S2r5R#3dBbs4%C ?=cEA]k䵱B"l\ G ? 1\Mu@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@A%尻,ϮC9O#c 8ҙil<(6bsu}_5fz8j eoREIz(:Cx^h5q"fߵRM#mvcD.iXfaZPjErK՝sxPtGHiN摈ߍP& 2Vřr jڇrhW0e%u,6;Mwe=ڕFco 89 +[ ˺Hhvv baIp AxquihaCLW dզV-r2ͷᅤTеߺZA\0c fv9=r.!tnwM55ʁ4d=ҁ\v׺I9^^N`MMj|76sNԸRcĂ;=JQ!jB =vL[a<|.<@bP]G\ZL5Ѳ.V᷌KZbvjէx(5w5qn_5mw&\ސl]3F*4m'705񼲣֐G9O }uE58ɘ Alrr蝃[ƂZ8v//pF(,N&8p(0HbPre.`yvVP]A{ԶbB qRdhz"k9v@zֆPcǕiCM8]Jyq 3P@" 0P1dM x%­ڃ ӬmkpuZj 08Ew_3TS&ֿ[dpv F e6 >_ %%y x\ړJ6 - pރc#94;)Nd8 08֧Z΃P@iliq9}2x4Qߎ PҔxj>t6PcPK!ή&A66676@@@AQT@7 -O VhsO -+psCj* reͼ1+\Mu@@@@@@@@@@@@Ak&Y0(9Aj7=v"&y=Sb:/Ұb`̃˦t6sZoނ‚׳^X{$ Ԑ)ʂv3q,hiw u@@@@@@@@@@@A9`l2&.cN*jM !”y(-7̃o-+k: 3 9\文pW+I#r23RwaʂȀ;Z6atXx8J}\]dH{Z5{ 6|: tOM|,ֿ7̃u23Xb}v)CiˉA.~ @@A\-5mwm9ܾ!# ƣ:g; l&??TyDjQglm*0!)'2 =E7̃iolf7: QkiX1''#}{oo CQ,=ރ҂>+Hu2O xf6:MqPrs?A<|V o|*!^Ak}rm ]\퍑Av@AR@ߔYlYeNk̂Roȿ DxcO 6,tNX %Λz ;PZ/oPЃIe& ;x!/lqnA$}t Ì1̃X}|,#G\ػ 98is Zjb~4y" 4zٝ <P #iFA,5kZ(ր*z]1;p-6q %ծ#5k-_x!n h`9 1AS$oZ-NjokEQ4rc"`i  ăc@8xq&bn1$g3 h Xjq9(l"wcDb&cWH4bI(:Ni OWAH~׺P[PTu7Z޿yv" vۻF<@86k-w7`AQO [q"<1TާXymfV0#c[\e#fj{\ݿ*u͸kre.Pqn.Y@joIm'Y ۘ%PIZJX "!? 2ͥZÕ ݗtc[*O5 :2^NC4ZfPFC:v3!q'ɂ tۦkjsv8{O Dq!{:#j [=+G64\œ#%ܒ$? YYۆ1"XX(YCҪ 5M*;f`mpx{Pc&HA~oܤIp+OJ$̃'cXրִP g'V^jQ^ѧhZ;sRA|lDBʺUAr#d+jӓeD \rV]Db fZJd;Z*8 -^;G`ԏ H[A' sAsxnidt]f{\roA%gm{k$l4P w5AܵPi<ͬl7AAxJ#W?{2jruͳZX ׷oҁ-;h(Ӷoҁ-;x(Ӷoҁ-;h(Ӷoҁ{h{hޭf{CAo3߶g;տlh w~ٞ@V==ߵg;Ϳjh w~՞@0vyg;=`Yjh w;V{Aڳ՞@0vyg;==|y_hp|y_hp=|y uv|y_hp7 uv|y_hp=t=y Tbƒ(*'Aۭi3Shu): Yo3֒Ho14A#^VO pK&lZfټ| s^KeڃV##h@1PeI$[W&%7 dcj*^3 2\^X*A6(g)ix? A T`U:F9$%T[N V5l25ɋ!`LdtyvW3wPaH\ՠNꝁǸR@ڃ1$dMÅhABek=ҾIk#noM ?jEN*  =er^C#\ֹ.o@)"vW+moo%ͅAc{4 rmAqhmKEOA#mr\\2!{ia66wkeh%8f8E!kՊr`hxi W0% 4(._At kw<{ t-khG:"+ZWȃ1^Kc 1]\>6>0kq vymmw5qJs Nq5WZ&N`$v5aA]:5G8 :rْ~Pe6Irƈ8 gqPe/̃ol" PGcIڃVܹ 1۶Aa֘An̨_MkXk\CPݾ#)hz2n |{̃"͸`њ@[:b Y9H8f SyPb9ZJ$ $ (:v1 %q[EYFw1H|9yeƒymV!ǀ<4|xnZlA<<ԁ,;x(::uZ0Bwe䍸tws n\޸e&0ߘQ^n쥹ĩH'02f4U0i@I0 Gc13˸`X1+Jܤb̃Wsug>u$P]ÃlB8I~]1H5~J ~R ~J ~B ~B ~B ~B ~B ~1t۠@~Ӡat ?NkD ~@?hD?hD a4 ?FHG7gb  endstream endobj 67 0 obj<>stream JFIFddDucky<Adobed       h  !1AQaq"S2r5R#3dBbs4%C ?=cEA]k䵱B"l\ G ? 1\Mu@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@A%尻,ϮC9O#c 8ҙil<(6bsu}_5fz8j eoREIz(:Cx^h5q"fߵRM#mvcD.iXfaZPjErK՝sxPtGHiN摈ߍP& 2Vřr jڇrhW0e%u,6;Mwe=ڕFco 89 +[ ˺Hhvv baIp AxquihaCLW dզV-r2ͷᅤTеߺZA\0c fv9=r.!tnwM55ʁ4d=ҁ\v׺I9^^N`MMj|76sNԸRcĂ;=JQ!jB =vL[a<|.<@bP]G\ZL5Ѳ.V᷌KZbvjէx(5w5qn_5mw&\ސl]3F*4m'705񼲣֐G9O }uE58ɘ Alrr蝃[ƂZ8v//pF(,N&8p(0HbPre.`yvVP]A{ԶbB qRdhz"k9v@zֆPcǕiCM8]Jyq 3P@" 0P1dM x%­ڃ ӬmkpuZj 08Ew_3TS&ֿ[dpv F e6 >_ %%y x\ړJ6 - pރc#94;)Nd8 08֧Z΃P@iliq9}2x4Qߎ PҔxj>t6PcPK!ή&A66676@@@AQT@7 -O VhsO -+psCj* reͼ1+\Mu@@@@@@@@@@@@Ak&Y0(9Aj7=v"&y=Sb:/Ұb`̃˦t6sZoނ‚׳^X{$ Ԑ)ʂv3q,hiw u@@@@@@@@@@@A9`l2&.cN*jM !”y(-7̃o-+k: 3 9\文pW+I#r23RwaʂȀ;Z6atXx8J}\]dH{Z5{ 6|: tOM|,ֿ7̃u23Xb}v)CiˉA.~ @@A\-5mwm9ܾ!# ƣ:g; l&??TyDjQglm*0!)'2 =E7̃iolf7: QkiX1''#}{oo CQ,=ރ҂>+Hu2O xf6:MqPrs?A<|V o|*!^Ak}rm ]\퍑Av@AR@ߔYlYeNk̂Roȿ DxcO 6,tNX %Λz ;PZ/oPЃIe& ;x!/lqnA$}t Ì1̃X}|,#G\ػ 98is Zjb~4y" 4zٝ <P #iFA,5kZ(ր*z]1;p-6q %ծ#5k-_x!n h`9 1AS$oZ-NjokEQ4rc"`i  ăc@8xq&bn1$g3 h Xjq9(l"wcDb&cWH4bI(:Ni OWAH~׺P[PTu7Z޿yv" vۻF<@86k-w7`AQO [q"<1TާXymfV0#c[\e#fj{\ݿ*u͸kre.Pqn.Y@joIm'Y ۘ%PIZJX "!? 2ͥZÕ ݗtc[*O5 :2^NC4ZfPFC:v3!q'ɂ tۦkjsv8{O Dq!{:#j [=+G64\œ#%ܒ$? YYۆ1"XX(YCҪ 5M*;f`mpx{Pc&HA~oܤIp+OJ$̃'cXրִP g'V^jQ^ѧhZ;sRA|lDBʺUAr#d+jӓeD \rV]Db fZJd;Z*8 -^;G`ԏ H[A' sAsxnidt]f{\roA%gm{k$l4P w5AܵPi<ͬl7AAxJ#W?{2jruͳZX ׷oҁ-;h(Ӷoҁ-;x(Ӷoҁ-;h(Ӷoҁ{h{hޭf{CAo3߶g;տlh w~ٞ@V==ߵg;Ϳjh w~՞@0vyg;=`Yjh w;V{Aڳ՞@0vyg;==|y_hp|y_hp=|y uv|y_hp7 uv|y_hp=t=y Tbƒ(*'Aۭi3Shu): Yo3֒Ho14A#^VO pK&lZfټ| s^KeڃV##h@1PeI$[W&%7 dcj*^3 2\^X*A6(g)ix? A T`U:F9$%T[N V5l25ɋ!`LdtyvW3wPaH\ՠNꝁǸR@ڃ1$dMÅhABek=ҾIk#noM ?jEN*  =er^C#\ֹ.o@)"vW+moo%ͅAc{4 rmAqhmKEOA#mr\\2!{ia66wkeh%8f8E!kՊr`hxi W0% 4(._At kw<{ t-khG:"+ZWȃ1^Kc 1]\>6>0kq vymmw5qJs Nq5WZ&N`$v5aA]:5G8 :rْ~Pe6Irƈ8 gqPe/̃ol" PGcIڃVܹ 1۶Aa֘An̨_MkXk\CPݾ#)hz2n |{̃"͸`њ@[:b Y9H8f SyPb9ZJ$ $ (:v1 %q[EYFw1H|9yeƒymV!ǀ<4|xnZlA<<ԁ,;x(::uZ0Bwe䍸tws n\޸e&0ߘQ^n쥹ĩH'02f4U0i@I0 Gc13˸`X1+Jܤb̃Wsug>u$P]ÃlB8I~]1H5~J ~R ~J ~B ~B ~B ~B ~B ~1t۠@~Ӡat ?NkD ~@?hD?hD a4 ?FHG7gb  endstream endobj 70 0 obj<>stream JFIFddDucky<Adobed       h  !1AQaq"S2r5R#3dBbs4%C ?=cEA]k䵱B"l\ G ? 1\Mu@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@A%尻,ϮC9O#c 8ҙil<(6bsu}_5fz8j eoREIz(:Cx^h5q"fߵRM#mvcD.iXfaZPjErK՝sxPtGHiN摈ߍP& 2Vřr jڇrhW0e%u,6;Mwe=ڕFco 89 +[ ˺Hhvv baIp AxquihaCLW dզV-r2ͷᅤTеߺZA\0c fv9=r.!tnwM55ʁ4d=ҁ\v׺I9^^N`MMj|76sNԸRcĂ;=JQ!jB =vL[a<|.<@bP]G\ZL5Ѳ.V᷌KZbvjէx(5w5qn_5mw&\ސl]3F*4m'705񼲣֐G9O }uE58ɘ Alrr蝃[ƂZ8v//pF(,N&8p(0HbPre.`yvVP]A{ԶbB qRdhz"k9v@zֆPcǕiCM8]Jyq 3P@" 0P1dM x%­ڃ ӬmkpuZj 08Ew_3TS&ֿ[dpv F e6 >_ %%y x\ړJ6 - pރc#94;)Nd8 08֧Z΃P@iliq9}2x4Qߎ PҔxj>t6PcPK!ή&A66676@@@AQT@7 -O VhsO -+psCj* reͼ1+\Mu@@@@@@@@@@@@Ak&Y0(9Aj7=v"&y=Sb:/Ұb`̃˦t6sZoނ‚׳^X{$ Ԑ)ʂv3q,hiw u@@@@@@@@@@@A9`l2&.cN*jM !”y(-7̃o-+k: 3 9\文pW+I#r23RwaʂȀ;Z6atXx8J}\]dH{Z5{ 6|: tOM|,ֿ7̃u23Xb}v)CiˉA.~ @@A\-5mwm9ܾ!# ƣ:g; l&??TyDjQglm*0!)'2 =E7̃iolf7: QkiX1''#}{oo CQ,=ރ҂>+Hu2O xf6:MqPrs?A<|V o|*!^Ak}rm ]\퍑Av@AR@ߔYlYeNk̂Roȿ DxcO 6,tNX %Λz ;PZ/oPЃIe& ;x!/lqnA$}t Ì1̃X}|,#G\ػ 98is Zjb~4y" 4zٝ <P #iFA,5kZ(ր*z]1;p-6q %ծ#5k-_x!n h`9 1AS$oZ-NjokEQ4rc"`i  ăc@8xq&bn1$g3 h Xjq9(l"wcDb&cWH4bI(:Ni OWAH~׺P[PTu7Z޿yv" vۻF<@86k-w7`AQO [q"<1TާXymfV0#c[\e#fj{\ݿ*u͸kre.Pqn.Y@joIm'Y ۘ%PIZJX "!? 2ͥZÕ ݗtc[*O5 :2^NC4ZfPFC:v3!q'ɂ tۦkjsv8{O Dq!{:#j [=+G64\œ#%ܒ$? YYۆ1"XX(YCҪ 5M*;f`mpx{Pc&HA~oܤIp+OJ$̃'cXրִP g'V^jQ^ѧhZ;sRA|lDBʺUAr#d+jӓeD \rV]Db fZJd;Z*8 -^;G`ԏ H[A' sAsxnidt]f{\roA%gm{k$l4P w5AܵPi<ͬl7AAxJ#W?{2jruͳZX ׷oҁ-;h(Ӷoҁ-;x(Ӷoҁ-;h(Ӷoҁ{h{hޭf{CAo3߶g;տlh w~ٞ@V==ߵg;Ϳjh w~՞@0vyg;=`Yjh w;V{Aڳ՞@0vyg;==|y_hp|y_hp=|y uv|y_hp7 uv|y_hp=t=y Tbƒ(*'Aۭi3Shu): Yo3֒Ho14A#^VO pK&lZfټ| s^KeڃV##h@1PeI$[W&%7 dcj*^3 2\^X*A6(g)ix? A T`U:F9$%T[N V5l25ɋ!`LdtyvW3wPaH\ՠNꝁǸR@ڃ1$dMÅhABek=ҾIk#noM ?jEN*  =er^C#\ֹ.o@)"vW+moo%ͅAc{4 rmAqhmKEOA#mr\\2!{ia66wkeh%8f8E!kՊr`hxi W0% 4(._At kw<{ t-khG:"+ZWȃ1^Kc 1]\>6>0kq vymmw5qJs Nq5WZ&N`$v5aA]:5G8 :rْ~Pe6Irƈ8 gqPe/̃ol" PGcIڃVܹ 1۶Aa֘An̨_MkXk\CPݾ#)hz2n |{̃"͸`њ@[:b Y9H8f SyPb9ZJ$ $ (:v1 %q[EYFw1H|9yeƒymV!ǀ<4|xnZlA<<ԁ,;x(::uZ0Bwe䍸tws n\޸e&0ߘQ^n쥹ĩH'02f4U0i@I0 Gc13˸`X1+Jܤb̃Wsug>u$P]ÃlB8I~]1H5~J ~R ~J ~B ~B ~B ~B ~B ~1t۠@~Ӡat ?NkD ~@?hD?hD a4 ?FHG7gb  endstream endobj 73 0 obj<>stream JFIFddDucky<Adobed       h  !1AQaq"S2r5R#3dBbs4%C ?=cEA]k䵱B"l\ G ? 1\Mu@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@A%尻,ϮC9O#c 8ҙil<(6bsu}_5fz8j eoREIz(:Cx^h5q"fߵRM#mvcD.iXfaZPjErK՝sxPtGHiN摈ߍP& 2Vřr jڇrhW0e%u,6;Mwe=ڕFco 89 +[ ˺Hhvv baIp AxquihaCLW dզV-r2ͷᅤTеߺZA\0c fv9=r.!tnwM55ʁ4d=ҁ\v׺I9^^N`MMj|76sNԸRcĂ;=JQ!jB =vL[a<|.<@bP]G\ZL5Ѳ.V᷌KZbvjէx(5w5qn_5mw&\ސl]3F*4m'705񼲣֐G9O }uE58ɘ Alrr蝃[ƂZ8v//pF(,N&8p(0HbPre.`yvVP]A{ԶbB qRdhz"k9v@zֆPcǕiCM8]Jyq 3P@" 0P1dM x%­ڃ ӬmkpuZj 08Ew_3TS&ֿ[dpv F e6 >_ %%y x\ړJ6 - pރc#94;)Nd8 08֧Z΃P@iliq9}2x4Qߎ PҔxj>t6PcPK!ή&A66676@@@AQT@7 -O VhsO -+psCj* reͼ1+\Mu@@@@@@@@@@@@Ak&Y0(9Aj7=v"&y=Sb:/Ұb`̃˦t6sZoނ‚׳^X{$ Ԑ)ʂv3q,hiw u@@@@@@@@@@@A9`l2&.cN*jM !”y(-7̃o-+k: 3 9\文pW+I#r23RwaʂȀ;Z6atXx8J}\]dH{Z5{ 6|: tOM|,ֿ7̃u23Xb}v)CiˉA.~ @@A\-5mwm9ܾ!# ƣ:g; l&??TyDjQglm*0!)'2 =E7̃iolf7: QkiX1''#}{oo CQ,=ރ҂>+Hu2O xf6:MqPrs?A<|V o|*!^Ak}rm ]\퍑Av@AR@ߔYlYeNk̂Roȿ DxcO 6,tNX %Λz ;PZ/oPЃIe& ;x!/lqnA$}t Ì1̃X}|,#G\ػ 98is Zjb~4y" 4zٝ <P #iFA,5kZ(ր*z]1;p-6q %ծ#5k-_x!n h`9 1AS$oZ-NjokEQ4rc"`i  ăc@8xq&bn1$g3 h Xjq9(l"wcDb&cWH4bI(:Ni OWAH~׺P[PTu7Z޿yv" vۻF<@86k-w7`AQO [q"<1TާXymfV0#c[\e#fj{\ݿ*u͸kre.Pqn.Y@joIm'Y ۘ%PIZJX "!? 2ͥZÕ ݗtc[*O5 :2^NC4ZfPFC:v3!q'ɂ tۦkjsv8{O Dq!{:#j [=+G64\œ#%ܒ$? YYۆ1"XX(YCҪ 5M*;f`mpx{Pc&HA~oܤIp+OJ$̃'cXրִP g'V^jQ^ѧhZ;sRA|lDBʺUAr#d+jӓeD \rV]Db fZJd;Z*8 -^;G`ԏ H[A' sAsxnidt]f{\roA%gm{k$l4P w5AܵPi<ͬl7AAxJ#W?{2jruͳZX ׷oҁ-;h(Ӷoҁ-;x(Ӷoҁ-;h(Ӷoҁ{h{hޭf{CAo3߶g;տlh w~ٞ@V==ߵg;Ϳjh w~՞@0vyg;=`Yjh w;V{Aڳ՞@0vyg;==|y_hp|y_hp=|y uv|y_hp7 uv|y_hp=t=y Tbƒ(*'Aۭi3Shu): Yo3֒Ho14A#^VO pK&lZfټ| s^KeڃV##h@1PeI$[W&%7 dcj*^3 2\^X*A6(g)ix? A T`U:F9$%T[N V5l25ɋ!`LdtyvW3wPaH\ՠNꝁǸR@ڃ1$dMÅhABek=ҾIk#noM ?jEN*  =er^C#\ֹ.o@)"vW+moo%ͅAc{4 rmAqhmKEOA#mr\\2!{ia66wkeh%8f8E!kՊr`hxi W0% 4(._At kw<{ t-khG:"+ZWȃ1^Kc 1]\>6>0kq vymmw5qJs Nq5WZ&N`$v5aA]:5G8 :rْ~Pe6Irƈ8 gqPe/̃ol" PGcIڃVܹ 1۶Aa֘An̨_MkXk\CPݾ#)hz2n |{̃"͸`њ@[:b Y9H8f SyPb9ZJ$ $ (:v1 %q[EYFw1H|9yeƒymV!ǀ<4|xnZlA<<ԁ,;x(::uZ0Bwe䍸tws n\޸e&0ߘQ^n쥹ĩH'02f4U0i@I0 Gc13˸`X1+Jܤb̃Wsug>u$P]ÃlB8I~]1H5~J ~R ~J ~B ~B ~B ~B ~B ~1t۠@~Ӡat ?NkD ~@?hD?hD a4 ?FHG7gb  endstream endobj 76 0 obj<>stream JFIFddDucky<Adobed       h  !1AQaq"S2r5R#3dBbs4%C ?=cEA]k䵱B"l\ G ? 1\Mu@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@A%尻,ϮC9O#c 8ҙil<(6bsu}_5fz8j eoREIz(:Cx^h5q"fߵRM#mvcD.iXfaZPjErK՝sxPtGHiN摈ߍP& 2Vřr jڇrhW0e%u,6;Mwe=ڕFco 89 +[ ˺Hhvv baIp AxquihaCLW dզV-r2ͷᅤTеߺZA\0c fv9=r.!tnwM55ʁ4d=ҁ\v׺I9^^N`MMj|76sNԸRcĂ;=JQ!jB =vL[a<|.<@bP]G\ZL5Ѳ.V᷌KZbvjէx(5w5qn_5mw&\ސl]3F*4m'705񼲣֐G9O }uE58ɘ Alrr蝃[ƂZ8v//pF(,N&8p(0HbPre.`yvVP]A{ԶbB qRdhz"k9v@zֆPcǕiCM8]Jyq 3P@" 0P1dM x%­ڃ ӬmkpuZj 08Ew_3TS&ֿ[dpv F e6 >_ %%y x\ړJ6 - pރc#94;)Nd8 08֧Z΃P@iliq9}2x4Qߎ PҔxj>t6PcPK!ή&A66676@@@AQT@7 -O VhsO -+psCj* reͼ1+\Mu@@@@@@@@@@@@Ak&Y0(9Aj7=v"&y=Sb:/Ұb`̃˦t6sZoނ‚׳^X{$ Ԑ)ʂv3q,hiw u@@@@@@@@@@@A9`l2&.cN*jM !”y(-7̃o-+k: 3 9\文pW+I#r23RwaʂȀ;Z6atXx8J}\]dH{Z5{ 6|: tOM|,ֿ7̃u23Xb}v)CiˉA.~ @@A\-5mwm9ܾ!# ƣ:g; l&??TyDjQglm*0!)'2 =E7̃iolf7: QkiX1''#}{oo CQ,=ރ҂>+Hu2O xf6:MqPrs?A<|V o|*!^Ak}rm ]\퍑Av@AR@ߔYlYeNk̂Roȿ DxcO 6,tNX %Λz ;PZ/oPЃIe& ;x!/lqnA$}t Ì1̃X}|,#G\ػ 98is Zjb~4y" 4zٝ <P #iFA,5kZ(ր*z]1;p-6q %ծ#5k-_x!n h`9 1AS$oZ-NjokEQ4rc"`i  ăc@8xq&bn1$g3 h Xjq9(l"wcDb&cWH4bI(:Ni OWAH~׺P[PTu7Z޿yv" vۻF<@86k-w7`AQO [q"<1TާXymfV0#c[\e#fj{\ݿ*u͸kre.Pqn.Y@joIm'Y ۘ%PIZJX "!? 2ͥZÕ ݗtc[*O5 :2^NC4ZfPFC:v3!q'ɂ tۦkjsv8{O Dq!{:#j [=+G64\œ#%ܒ$? YYۆ1"XX(YCҪ 5M*;f`mpx{Pc&HA~oܤIp+OJ$̃'cXրִP g'V^jQ^ѧhZ;sRA|lDBʺUAr#d+jӓeD \rV]Db fZJd;Z*8 -^;G`ԏ H[A' sAsxnidt]f{\roA%gm{k$l4P w5AܵPi<ͬl7AAxJ#W?{2jruͳZX ׷oҁ-;h(Ӷoҁ-;x(Ӷoҁ-;h(Ӷoҁ{h{hޭf{CAo3߶g;տlh w~ٞ@V==ߵg;Ϳjh w~՞@0vyg;=`Yjh w;V{Aڳ՞@0vyg;==|y_hp|y_hp=|y uv|y_hp7 uv|y_hp=t=y Tbƒ(*'Aۭi3Shu): Yo3֒Ho14A#^VO pK&lZfټ| s^KeڃV##h@1PeI$[W&%7 dcj*^3 2\^X*A6(g)ix? A T`U:F9$%T[N V5l25ɋ!`LdtyvW3wPaH\ՠNꝁǸR@ڃ1$dMÅhABek=ҾIk#noM ?jEN*  =er^C#\ֹ.o@)"vW+moo%ͅAc{4 rmAqhmKEOA#mr\\2!{ia66wkeh%8f8E!kՊr`hxi W0% 4(._At kw<{ t-khG:"+ZWȃ1^Kc 1]\>6>0kq vymmw5qJs Nq5WZ&N`$v5aA]:5G8 :rْ~Pe6Irƈ8 gqPe/̃ol" PGcIڃVܹ 1۶Aa֘An̨_MkXk\CPݾ#)hz2n |{̃"͸`њ@[:b Y9H8f SyPb9ZJ$ $ (:v1 %q[EYFw1H|9yeƒymV!ǀ<4|xnZlA<<ԁ,;x(::uZ0Bwe䍸tws n\޸e&0ߘQ^n쥹ĩH'02f4U0i@I0 Gc13˸`X1+Jܤb̃Wsug>u$P]ÃlB8I~]1H5~J ~R ~J ~B ~B ~B ~B ~B ~1t۠@~Ӡat ?NkD ~@?hD?hD a4 ?FHG7gb  endstream endobj 79 0 obj<>stream JFIFddDucky<Adobed       h  !1AQaq"S2r5R#3dBbs4%C ?=cEA]k䵱B"l\ G ? 1\Mu@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@A%尻,ϮC9O#c 8ҙil<(6bsu}_5fz8j eoREIz(:Cx^h5q"fߵRM#mvcD.iXfaZPjErK՝sxPtGHiN摈ߍP& 2Vřr jڇrhW0e%u,6;Mwe=ڕFco 89 +[ ˺Hhvv baIp AxquihaCLW dզV-r2ͷᅤTеߺZA\0c fv9=r.!tnwM55ʁ4d=ҁ\v׺I9^^N`MMj|76sNԸRcĂ;=JQ!jB =vL[a<|.<@bP]G\ZL5Ѳ.V᷌KZbvjէx(5w5qn_5mw&\ސl]3F*4m'705񼲣֐G9O }uE58ɘ Alrr蝃[ƂZ8v//pF(,N&8p(0HbPre.`yvVP]A{ԶbB qRdhz"k9v@zֆPcǕiCM8]Jyq 3P@" 0P1dM x%­ڃ ӬmkpuZj 08Ew_3TS&ֿ[dpv F e6 >_ %%y x\ړJ6 - pރc#94;)Nd8 08֧Z΃P@iliq9}2x4Qߎ PҔxj>t6PcPK!ή&A66676@@@AQT@7 -O VhsO -+psCj* reͼ1+\Mu@@@@@@@@@@@@Ak&Y0(9Aj7=v"&y=Sb:/Ұb`̃˦t6sZoނ‚׳^X{$ Ԑ)ʂv3q,hiw u@@@@@@@@@@@A9`l2&.cN*jM !”y(-7̃o-+k: 3 9\文pW+I#r23RwaʂȀ;Z6atXx8J}\]dH{Z5{ 6|: tOM|,ֿ7̃u23Xb}v)CiˉA.~ @@A\-5mwm9ܾ!# ƣ:g; l&??TyDjQglm*0!)'2 =E7̃iolf7: QkiX1''#}{oo CQ,=ރ҂>+Hu2O xf6:MqPrs?A<|V o|*!^Ak}rm ]\퍑Av@AR@ߔYlYeNk̂Roȿ DxcO 6,tNX %Λz ;PZ/oPЃIe& ;x!/lqnA$}t Ì1̃X}|,#G\ػ 98is Zjb~4y" 4zٝ <P #iFA,5kZ(ր*z]1;p-6q %ծ#5k-_x!n h`9 1AS$oZ-NjokEQ4rc"`i  ăc@8xq&bn1$g3 h Xjq9(l"wcDb&cWH4bI(:Ni OWAH~׺P[PTu7Z޿yv" vۻF<@86k-w7`AQO [q"<1TާXymfV0#c[\e#fj{\ݿ*u͸kre.Pqn.Y@joIm'Y ۘ%PIZJX "!? 2ͥZÕ ݗtc[*O5 :2^NC4ZfPFC:v3!q'ɂ tۦkjsv8{O Dq!{:#j [=+G64\œ#%ܒ$? YYۆ1"XX(YCҪ 5M*;f`mpx{Pc&HA~oܤIp+OJ$̃'cXրִP g'V^jQ^ѧhZ;sRA|lDBʺUAr#d+jӓeD \rV]Db fZJd;Z*8 -^;G`ԏ H[A' sAsxnidt]f{\roA%gm{k$l4P w5AܵPi<ͬl7AAxJ#W?{2jruͳZX ׷oҁ-;h(Ӷoҁ-;x(Ӷoҁ-;h(Ӷoҁ{h{hޭf{CAo3߶g;տlh w~ٞ@V==ߵg;Ϳjh w~՞@0vyg;=`Yjh w;V{Aڳ՞@0vyg;==|y_hp|y_hp=|y uv|y_hp7 uv|y_hp=t=y Tbƒ(*'Aۭi3Shu): Yo3֒Ho14A#^VO pK&lZfټ| s^KeڃV##h@1PeI$[W&%7 dcj*^3 2\^X*A6(g)ix? A T`U:F9$%T[N V5l25ɋ!`LdtyvW3wPaH\ՠNꝁǸR@ڃ1$dMÅhABek=ҾIk#noM ?jEN*  =er^C#\ֹ.o@)"vW+moo%ͅAc{4 rmAqhmKEOA#mr\\2!{ia66wkeh%8f8E!kՊr`hxi W0% 4(._At kw<{ t-khG:"+ZWȃ1^Kc 1]\>6>0kq vymmw5qJs Nq5WZ&N`$v5aA]:5G8 :rْ~Pe6Irƈ8 gqPe/̃ol" PGcIڃVܹ 1۶Aa֘An̨_MkXk\CPݾ#)hz2n |{̃"͸`њ@[:b Y9H8f SyPb9ZJ$ $ (:v1 %q[EYFw1H|9yeƒymV!ǀ<4|xnZlA<<ԁ,;x(::uZ0Bwe䍸tws n\޸e&0ߘQ^n쥹ĩH'02f4U0i@I0 Gc13˸`X1+Jܤb̃Wsug>u$P]ÃlB8I~]1H5~J ~R ~J ~B ~B ~B ~B ~B ~1t۠@~Ӡat ?NkD ~@?hD?hD a4 ?FHG7gb  endstream endobj 82 0 obj<>stream JFIFddDucky<Adobed       h  !1AQaq"S2r5R#3dBbs4%C ?=cEA]k䵱B"l\ G ? 1\Mu@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@A%尻,ϮC9O#c 8ҙil<(6bsu}_5fz8j eoREIz(:Cx^h5q"fߵRM#mvcD.iXfaZPjErK՝sxPtGHiN摈ߍP& 2Vřr jڇrhW0e%u,6;Mwe=ڕFco 89 +[ ˺Hhvv baIp AxquihaCLW dզV-r2ͷᅤTеߺZA\0c fv9=r.!tnwM55ʁ4d=ҁ\v׺I9^^N`MMj|76sNԸRcĂ;=JQ!jB =vL[a<|.<@bP]G\ZL5Ѳ.V᷌KZbvjէx(5w5qn_5mw&\ސl]3F*4m'705񼲣֐G9O }uE58ɘ Alrr蝃[ƂZ8v//pF(,N&8p(0HbPre.`yvVP]A{ԶbB qRdhz"k9v@zֆPcǕiCM8]Jyq 3P@" 0P1dM x%­ڃ ӬmkpuZj 08Ew_3TS&ֿ[dpv F e6 >_ %%y x\ړJ6 - pރc#94;)Nd8 08֧Z΃P@iliq9}2x4Qߎ PҔxj>t6PcPK!ή&A66676@@@AQT@7 -O VhsO -+psCj* reͼ1+\Mu@@@@@@@@@@@@Ak&Y0(9Aj7=v"&y=Sb:/Ұb`̃˦t6sZoނ‚׳^X{$ Ԑ)ʂv3q,hiw u@@@@@@@@@@@A9`l2&.cN*jM !”y(-7̃o-+k: 3 9\文pW+I#r23RwaʂȀ;Z6atXx8J}\]dH{Z5{ 6|: tOM|,ֿ7̃u23Xb}v)CiˉA.~ @@A\-5mwm9ܾ!# ƣ:g; l&??TyDjQglm*0!)'2 =E7̃iolf7: QkiX1''#}{oo CQ,=ރ҂>+Hu2O xf6:MqPrs?A<|V o|*!^Ak}rm ]\퍑Av@AR@ߔYlYeNk̂Roȿ DxcO 6,tNX %Λz ;PZ/oPЃIe& ;x!/lqnA$}t Ì1̃X}|,#G\ػ 98is Zjb~4y" 4zٝ <P #iFA,5kZ(ր*z]1;p-6q %ծ#5k-_x!n h`9 1AS$oZ-NjokEQ4rc"`i  ăc@8xq&bn1$g3 h Xjq9(l"wcDb&cWH4bI(:Ni OWAH~׺P[PTu7Z޿yv" vۻF<@86k-w7`AQO [q"<1TާXymfV0#c[\e#fj{\ݿ*u͸kre.Pqn.Y@joIm'Y ۘ%PIZJX "!? 2ͥZÕ ݗtc[*O5 :2^NC4ZfPFC:v3!q'ɂ tۦkjsv8{O Dq!{:#j [=+G64\œ#%ܒ$? YYۆ1"XX(YCҪ 5M*;f`mpx{Pc&HA~oܤIp+OJ$̃'cXրִP g'V^jQ^ѧhZ;sRA|lDBʺUAr#d+jӓeD \rV]Db fZJd;Z*8 -^;G`ԏ H[A' sAsxnidt]f{\roA%gm{k$l4P w5AܵPi<ͬl7AAxJ#W?{2jruͳZX ׷oҁ-;h(Ӷoҁ-;x(Ӷoҁ-;h(Ӷoҁ{h{hޭf{CAo3߶g;տlh w~ٞ@V==ߵg;Ϳjh w~՞@0vyg;=`Yjh w;V{Aڳ՞@0vyg;==|y_hp|y_hp=|y uv|y_hp7 uv|y_hp=t=y Tbƒ(*'Aۭi3Shu): Yo3֒Ho14A#^VO pK&lZfټ| s^KeڃV##h@1PeI$[W&%7 dcj*^3 2\^X*A6(g)ix? A T`U:F9$%T[N V5l25ɋ!`LdtyvW3wPaH\ՠNꝁǸR@ڃ1$dMÅhABek=ҾIk#noM ?jEN*  =er^C#\ֹ.o@)"vW+moo%ͅAc{4 rmAqhmKEOA#mr\\2!{ia66wkeh%8f8E!kՊr`hxi W0% 4(._At kw<{ t-khG:"+ZWȃ1^Kc 1]\>6>0kq vymmw5qJs Nq5WZ&N`$v5aA]:5G8 :rْ~Pe6Irƈ8 gqPe/̃ol" PGcIڃVܹ 1۶Aa֘An̨_MkXk\CPݾ#)hz2n |{̃"͸`њ@[:b Y9H8f SyPb9ZJ$ $ (:v1 %q[EYFw1H|9yeƒymV!ǀ<4|xnZlA<<ԁ,;x(::uZ0Bwe䍸tws n\޸e&0ߘQ^n쥹ĩH'02f4U0i@I0 Gc13˸`X1+Jܤb̃Wsug>u$P]ÃlB8I~]1H5~J ~R ~J ~B ~B ~B ~B ~B ~1t۠@~Ӡat ?NkD ~@?hD?hD a4 ?FHG7gb  endstream endobj 85 0 obj<>stream JFIFddDucky<Adobed       h  !1AQaq"S2r5R#3dBbs4%C ?=cEA]k䵱B"l\ G ? 1\Mu@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@A%尻,ϮC9O#c 8ҙil<(6bsu}_5fz8j eoREIz(:Cx^h5q"fߵRM#mvcD.iXfaZPjErK՝sxPtGHiN摈ߍP& 2Vřr jڇrhW0e%u,6;Mwe=ڕFco 89 +[ ˺Hhvv baIp AxquihaCLW dզV-r2ͷᅤTеߺZA\0c fv9=r.!tnwM55ʁ4d=ҁ\v׺I9^^N`MMj|76sNԸRcĂ;=JQ!jB =vL[a<|.<@bP]G\ZL5Ѳ.V᷌KZbvjէx(5w5qn_5mw&\ސl]3F*4m'705񼲣֐G9O }uE58ɘ Alrr蝃[ƂZ8v//pF(,N&8p(0HbPre.`yvVP]A{ԶbB qRdhz"k9v@zֆPcǕiCM8]Jyq 3P@" 0P1dM x%­ڃ ӬmkpuZj 08Ew_3TS&ֿ[dpv F e6 >_ %%y x\ړJ6 - pރc#94;)Nd8 08֧Z΃P@iliq9}2x4Qߎ PҔxj>t6PcPK!ή&A66676@@@AQT@7 -O VhsO -+psCj* reͼ1+\Mu@@@@@@@@@@@@Ak&Y0(9Aj7=v"&y=Sb:/Ұb`̃˦t6sZoނ‚׳^X{$ Ԑ)ʂv3q,hiw u@@@@@@@@@@@A9`l2&.cN*jM !”y(-7̃o-+k: 3 9\文pW+I#r23RwaʂȀ;Z6atXx8J}\]dH{Z5{ 6|: tOM|,ֿ7̃u23Xb}v)CiˉA.~ @@A\-5mwm9ܾ!# ƣ:g; l&??TyDjQglm*0!)'2 =E7̃iolf7: QkiX1''#}{oo CQ,=ރ҂>+Hu2O xf6:MqPrs?A<|V o|*!^Ak}rm ]\퍑Av@AR@ߔYlYeNk̂Roȿ DxcO 6,tNX %Λz ;PZ/oPЃIe& ;x!/lqnA$}t Ì1̃X}|,#G\ػ 98is Zjb~4y" 4zٝ <P #iFA,5kZ(ր*z]1;p-6q %ծ#5k-_x!n h`9 1AS$oZ-NjokEQ4rc"`i  ăc@8xq&bn1$g3 h Xjq9(l"wcDb&cWH4bI(:Ni OWAH~׺P[PTu7Z޿yv" vۻF<@86k-w7`AQO [q"<1TާXymfV0#c[\e#fj{\ݿ*u͸kre.Pqn.Y@joIm'Y ۘ%PIZJX "!? 2ͥZÕ ݗtc[*O5 :2^NC4ZfPFC:v3!q'ɂ tۦkjsv8{O Dq!{:#j [=+G64\œ#%ܒ$? YYۆ1"XX(YCҪ 5M*;f`mpx{Pc&HA~oܤIp+OJ$̃'cXրִP g'V^jQ^ѧhZ;sRA|lDBʺUAr#d+jӓeD \rV]Db fZJd;Z*8 -^;G`ԏ H[A' sAsxnidt]f{\roA%gm{k$l4P w5AܵPi<ͬl7AAxJ#W?{2jruͳZX ׷oҁ-;h(Ӷoҁ-;x(Ӷoҁ-;h(Ӷoҁ{h{hޭf{CAo3߶g;տlh w~ٞ@V==ߵg;Ϳjh w~՞@0vyg;=`Yjh w;V{Aڳ՞@0vyg;==|y_hp|y_hp=|y uv|y_hp7 uv|y_hp=t=y Tbƒ(*'Aۭi3Shu): Yo3֒Ho14A#^VO pK&lZfټ| s^KeڃV##h@1PeI$[W&%7 dcj*^3 2\^X*A6(g)ix? 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[(lifetime)-617(risk)-617(of)-617(acquisition)-617(of)-617(IE,)-617(such)-617(as)-617(mitral)-617(valve)]TJ T* [(prolapse)-278(\(MVP\),)-278(had)-278(a)-278(sense)-278(of)-278(reassurance)-278(and)-278(comfort)-278(that)]TJ T* [(antibiotics)-408(administered)-408(in)-408(association)-408(with)-408(a)-408(dental)-408(proce-)]TJ T* [(dure)-241(were)-241(effective)-241(and)-241(usually)-241(safe)-241(to)-241(prevent)-241(IE.)-241(Healthcare)]TJ T* [(providers,)-378(especially)-378(dentists,)-378(felt)-378(a)-378(sense)-378(of)-378(obligation)-378(and)]TJ T* [(professional)-345(and)-345(legal)-345(responsibility)-345(to)-345(protect)-345(their)-345(patients)]TJ 0 -1.214 TD [(from)-343(IE)-343(that)-343(might)-343(result)-343(from)-343(a)-343(procedure.)-343(On)-343(the)-343(basis)-343(of)]TJ T* [(recommendations)-633(in)-633(this)-633(revised)-633(document,)-633(substantially)]TJ T* [(fewer)-333(patients)-333(will)-333(be)-333(recommended)-333(for)-333(IE)-333(prophylaxis.)]TJ 1 -1.214 Td 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[(subject)-342(to)-342(conflicting)-342(interpretations)-342(among)-342(patients,)-342(health-)]TJ 0 -1.214 TD [(care)-340(providers,)-340(and)-340(the)-340(legal)-340(system)-340(about)-340(patient)-340(eligibility)]TJ T* [(for)-434(prophylaxis)-434(and)-434(whether)-434(there)-434(was)-434(strict)-434(adherence)-434(by)]TJ T* [(healthcare)-393(providers)-393(to)-393(AHA)-393(recommendations)-393(for)-393(prophy-)]TJ T* [(laxis.)-419(This)-419(document)-419(is)-419(intended)-419(to)-419(identify)-419(which,)-419(if)-419(any,)]TJ T* [(patients)-482(may)-482(possibly)-482(benefit)-482(from)-482(IE)-482(prophylaxis)-482(and)-482(to)]TJ 27.158 70.474 Td [(define,)-246(to)-246(the)-246(extent)-246(possible,)-246(which)-246(dental)-246(procedures)-246(should)]TJ 0 -1.223 TD [(have)-465(prophylaxis)-465(in)-465(this)-465(select)-465(group)-465(of)-465(patients.)-465(Accord-)]TJ T* [(ingly,)-320(the)-320(Committee)-320(hopes)-320(that)-320(this)-320(document)-320(will)-320(result)-320(in)]TJ T* [(greater)-282(clarity)-282(for)-282(patients,)-282(healthcare)-282(providers,)-282(and)-282(consult-)]TJ T* [(ing)-333(professionals.)]TJ 1 -1.223 Td [(The)-606(Committee)-606(believes)-606(that)-606(recommendations)-606(for)-606(IE)]TJ -1 -1.223 Td [(prophylaxis)-412(must)-412(be)-412(evidence)-412(based.)-412(A)-412(placebo-controlled,)]TJ T* [(multicenter,)-505(randomized,)-505(double-blinded)-505(study)-505(to)-505(evaluate)]TJ T* [(the)-484(efficacy)-484(of)-484(IE)-484(prophylaxis)-484(in)-484(patients)-484(who)-484(undergo)-484(a)]TJ T* [(dental,)-313(GI,)-313(or)-313(GU)-313(tract)-313(procedure)-313(has)-313(not)-313(been)-313(done.)-313(Such)-313(a)]TJ T* [(study)-293(would)-293(require)-293(a)-293(large)-293(number)-293(of)-293(patients)-293(per)-293(treatment)]TJ T* [(group)-266(and)-266(standardization)-266(of)-266(the)-266(specific)-266(invasive)-266(procedures)]TJ T* [(and)-487(the)-487(patient)-487(populations.)-487(This)-487(type)-487(of)-487(study)-487(would)-487(be)]TJ T* [(necessary)-527(to)-527(definitively)-527(answer)-527(long-standing)-527(unresolved)]TJ T* [(questions)-611(regarding)-611(the)-611(efficacy)-611(of)-611(IE)-611(prophylaxis.)-611(The)]TJ T* [(Committee)-408(hopes)-408(that)-408(this)-408(revised)-408(document)-408(will)-408(stimulate)]TJ T* [(additional)-354(studies)-354(on)-354(the)-354(prevention)-354(of)-354(IE.)-354(Future)-354(published)]TJ T* [(data)-327(will)-327(be)-327(reviewed)-327(carefully)-327(by)-327(the)-327(AHA,)-327(the)-327(Committee)]TJ T* [(on)-454(Rheumatic)-454(Fever,)-454(Endocarditis,)-454(and)-454(Kawasaki)-454(Disease,)]TJ T* [(and)-597(other)-597(societies,)-597(and)-597(further)-597(revisions)-597(to)-597(the)-597(present)]TJ T* [(document)-333(will)-333(be)-333(based)-333(on)-333(relevant)-333(studies.)]TJ /T1_1 1 Tf 11.5 0 0 11.5 384.8551 464.4972 Tm [(Pathogenesis)-333(of)-333(IE)]TJ /T1_0 1 Tf 9.5 0 0 9.5 314.1648 453.3835 Tm [(The)-530(development)-530(of)-530(IE)-530(is)-530(the)-530(net)-530(result)-530(of)-530(the)-530(complex)]TJ 0 -1.222 TD [(interaction)-467(between)-467(the)-467(bloodstream)-467(pathogen)-467(with)-467(matrix)]TJ T* [(molecules)-241(and)-241(platelets)-241(at)-241(sites)-241(of)-241(endocardial)-241(cell)-241(damage.)-241(In)]TJ 0 -1.222 TD [(addition,)-368(many)-368(of)-368(the)-368(clinical)-368(manifestations)-368(of)-368(IE)-368(emanate)]TJ 0 -1.223 TD [(from)-406(the)-406(host\222s)-406(immune)-406(response)-406(to)-406(the)-406(infecting)-406(microor-)]TJ T* [(ganism.)-253(The)-253(following)-253(sequence)-253(of)-253(events)-253(is)-253(thought)-253(to)-253(result)]TJ T* [(in)-606(IE:)-606(formation)-606(of)-606(nonbacterial)-606(thrombotic)-606(endocarditis)]TJ 0 -1.222 TD [(\(NBTE\))-358(on)-358(the)-358(surface)-358(of)-358(a)-358(cardiac)-358(valve)-358(or)-358(elsewhere)-358(that)]TJ 0 -1.223 TD [(endothelial)-579(damage)-579(occurs,)-579(bacteremia,)-579(adherence)-579(of)-579(the)]TJ T* [(bacteria)-451(in)-451(the)-451(bloodstream)-451(to)-451(NBTE,)-451(and)-451(proliferation)-451(of)]TJ T* [(bacteria)-333(within)-333(a)-333(vegetation.)]TJ /T1_1 1 Tf 10.5 0 0 10.5 314.1648 315.1335 Tm [(Formation)-333(of)-333(NBTE)]TJ /T1_0 1 Tf 9.5 0 0 9.5 314.1648 304.0313 Tm [(Turbulent)-253(blood)-253(flow)-253(produced)-253(by)-253(certain)-253(types)-253(of)-253(congenital)]TJ 0 -1.221 TD [(or)-454(acquired)-454(heart)-454(disease,)-454(such)-454(as)-454(flow)-454(from)-454(a)-454(high-)-454(to)-454(a)]TJ T* [(low-pressure)-358(chamber)-358(or)-358(across)-358(a)-358(narrowed)-358(orifice,)-358(trauma-)]TJ T* [(tizes)-643(the)-643(endothelium.)-643(This)-643(creates)-643(a)-643(predisposition)-643(for)]TJ T* [(deposition)-608(of)-608(platelets)-608(and)-608(fibrin)-608(on)-608(the)-608(surface)-608(of)-608(the)]TJ 0 -1.221 TD [(endothelium,)-322(which)-322(results)-322(in)-322(NBTE.)-322(Invasion)-322(of)-322(the)-322(blood-)]TJ T* [(stream)-573(with)-573(a)-573(microbial)-573(species)-573(that)-573(has)-573(the)-573(pathogenic)]TJ T* [(potential)-333(to)-333(colonize)-333(this)-333(site)-333(can)-333(then)-333(result)-333(in)-333(IE.)]TJ /T1_1 1 Tf 10.5 0 0 10.5 314.1648 200.7131 Tm [(Transient)-333(Bacteremia)]TJ /T1_0 1 Tf 9.5 0 0 9.5 314.1648 189.6109 Tm [(Mucosal)-607(surfaces)-607(are)-607(populated)-607(by)-607(a)-607(dense)-607(endogenous)]TJ 0 -1.221 TD [(microflora.)-504(Trauma)-504(to)-504(a)-504(mucosal)-504(surface,)-504(particularly)-504(the)]TJ T* [(gingival)-353(crevice)-353(around)-353(teeth,)-353(oropharynx,)-353(GI)-353(tract,)-353(urethra,)]TJ T* [(and)-405(vagina,)-405(releases)-405(many)-405(different)-405(microbial)-405(species)-405(tran-)]TJ T* [(siently)-301(into)-301(the)-301(bloodstream.)-301(Transient)-301(bacteremia)-301(caused)-301(by)]TJ 0 -1.221 TD [(viridans)-337(group)-337(streptococci)-337(and)-337(other)-337(oral)-337(microflora)-337(occurs)]TJ T* [(commonly)-519(in)-519(association)-519(with)-519(dental)-519(extractions)-519(or)-519(other)]TJ T* [(dental)-388(procedures)-388(or)-388(with)-388(routine)-388(daily)-388(activities.)-388(Although)]TJ T* [(controversial,)-500(the)-500(frequency)-500(and)-500(intensity)-500(of)-500(the)-500(resulting)]TJ T* [(bacteremias)-540(are)-540(believed)-540(to)-540(be)-540(related)-540(to)-540(the)-540(nature)-540(and)]TJ T* [(magnitude)-339(of)-339(the)-339(tissue)-339(trauma,)-339(the)-339(density)-339(of)-339(the)-339(microbial)]TJ T* [(flora,)-322(and)-322(the)-322(degree)-322(of)-322(inflammation)-322(or)-322(infection)-322(at)-322(the)-322(site)]TJ T* [(of)-532(trauma.)-532(The)-532(microbial)-532(species)-532(entering)-532(the)-532(circulation)]TJ /T1_2 1 Tf 10 0 0 10 56.1648 752.3835 Tm [(4)-2000(Circulation)]TJ /T1_1 1 Tf 9.224 0 Td [(May)-333(8,)-333(2007)]TJ 0 g ET /GS1 gs BT /T1_3 1 Tf 9 0 0 9 294.7364 32 Tm ( by WARREN WALSH on April 19, 2007 )Tj 0 0 1 rg ET /GS1 gs BT /T1_3 1 Tf 9 0 0 9 223.2585 32 Tm (circ.ahajournals.org)Tj 0 g ET /GS1 gs BT /T1_3 1 Tf 9 0 0 9 155.2727 32 Tm (Downloaded from )Tj ET endstream endobj 220 0 obj<> endobj 221 0 obj<> endobj 222 0 obj[220 0 R] endobj 223 0 obj<> endobj 226 0 obj<>stream q 360 0 0 139 129 259 cm /Im0 Do Q 0 0 0 1 k 1 i /GS0 gs BT /T1_0 1 Tf 0 Tc 0 Tw 0 Ts 100 Tz 0 Tr 9.5 0 0 9.5 56.1648 719.8835 Tm [(depends)-305(on)-305(the)-305(unique)-305(endogenous)-305(microflora)-305(that)-305(colonizes)]TJ 0 -1.215 TD [(the)-333(particular)-333(traumatized)-333(site.)]TJ /T1_1 1 Tf 10.5 0 0 10.5 56.1648 686.2927 Tm [(Bacterial)-333(Adherence)]TJ /T1_0 1 Tf 9.5 0 0 9.5 56.1648 675.2472 Tm [(The)-299(ability)-299(of)-299(various)-299(microbial)-299(species)-299(to)-299(adhere)-299(to)-299(specific)]TJ T* [(sites)-258(determines)-258(the)-258(anatomic)-258(localization)-258(of)-258(infection)-258(caused)]TJ T* [(by)-417(these)-417(microorganisms.)-417(Mediators)-417(of)-417(bacterial)-417(adherence)]TJ 0 -1.215 TD [(serve)-327(as)-327(virulence)-327(factors)-327(in)-327(the)-327(pathogenesis)-327(of)-327(IE.)-327(Numer-)]TJ 0 -1.215 TD [(ous)-556(bacterial)-556(surface)-556(components)-556(present)-556(in)-556(streptococci,)]TJ T* [(staphylococci,)-420(and)-420(enterococci)-420(have)-420(been)-420(shown)-420(in)-420(animal)]TJ T* [(models)-440(of)-440(experimental)-440(endocarditis)-440(to)-440(function)-440(as)-440(critical)]TJ T* [(adhesins.)-365(Some)-365(viridans)-365(group)-365(streptococci)-365(contain)-365(a)-365(FimA)]TJ 0 -1.215 TD [(protein)-484(that)-484(is)-484(a)-484(lipoprotein)-484(receptor)-484(antigen)-484(I)-484(\(LraI\))-484(that)]TJ 0 -1.214 TD [(serves)-486(as)-486(a)-486(major)-486(adhesin)-486(to)-486(the)-486(fibrin)-486(platelet)-486(matrix)-486(of)]TJ T* (NBTE.)Tj 6.5 0 0 5.5 83.3429 562.3466 Tm (17)Tj 9.5 0 0 9.5 92.292 559.8154 Tm [(Staphylococcal)-258(adhesins)-258(function)-258(in)-258(at)-258(least)-258(2)-258(ways.)]TJ -3.803 -1.214 Td [(In)-389(one,)-389(microbial)-389(surface)-389(components)-389(recognizing)-389(adhesive)]TJ 0 -1.214 TD [(matrix)-250(molecules)-250(facilitate)-250(the)-250(attachment)-250(of)-250(staphylococci)-250(to)]TJ 0 -1.214 TD [(human)-385(extracellular)-385(matrix)-385(proteins)-385(and)-385(to)-385(medical)-385(devices)]TJ 0 -1.214 TD [(that)-229(become)-229(coated)-229(with)-229(matrix)-229(proteins)-229(after)-229(implantation.)-229(In)]TJ T* [(the)-389(other,)-389(bacterial)-389(extracellular)-389(structures)-389(contribute)-389(to)-389(the)]TJ T* [(formation)-349(of)-349(biofilm)-349(that)-349(forms)-349(on)-349(the)-349(surface)-349(of)-349(implanted)]TJ 0 -1.214 TD [(medical)-377(devices.)-377(In)-377(both)-377(cases,)-377(staphylococcal)-377(adhesins)-377(are)]TJ 0 -1.214 TD [(important)-333(virulence)-333(factors.)]TJ 1 -1.214 Td [(Both)-300(FimA)-300(and)-300(staphylococcal)-300(adhesins)-300(are)-300(immunogenic)]TJ -1 -1.214 Td [(in)-352(experimental)-352(infections.)-352(Vaccines)-352(prepared)-352(against)-352(FimA)]TJ T* [(and)-226(staphylococcal)-226(adhesins)-226(provide)-226(some)-226(protective)-226(effect)-226(in)]TJ T* [(experimental)-366(endocarditis)-366(caused)-366(by)-366(viridans)-366(group)-366(strepto-)]TJ T* [(cocci)-312(and)-312(staphylococci.)]TJ 6.5 0 0 5.5 150.4649 412.4035 Tm (18,19)Tj 9.5 0 0 9.5 168.0535 409.8722 Tm [(The)-312(results)-312(of)-312(these)-312(experimen-)]TJ -11.778 -1.214 Td [(tal)-312(studies)-312(are)-312(highly)-312(intriguing,)-312(because)-312(the)-312(development)-312(of)]TJ 0 -1.214 TD [(an)-416(effective)-416(vaccine)-416(for)-417(use)-416(in)-416(humans)-416(to)-416(prevent)-417(viridans)]TJ 0 -1.214 TD [(group)-337(streptococcal)-337(or)-337(staphylococcal)-337(IE)-337(would)-337(be)-337(of)-337(major)]TJ 0 -1.214 TD (importance.)Tj /T1_1 1 Tf 10.5 0 0 10.5 56.1648 341.7018 Tm [(Proliferation)-333(of)-333(Bacteria)-333(Within)-333(a)-333(Vegetation)]TJ /T1_0 1 Tf 9.5 0 0 9.5 56.1648 330.6676 Tm [(Microorganisms)-347(adherent)-347(to)-347(the)-347(vegetation)-347(stimulate)-347(further)]TJ 0 -1.214 TD [(deposition)-271(of)-271(fibrin)-271(and)-271(platelets)-271(on)-271(their)-271(surface.)-271(Within)-271(this)]TJ T* [(secluded)-381(focus,)-381(the)-381(buried)-381(microorganisms)-381(multiply)-381(as)-381(rap-)]TJ 0 -1.214 TD [(idly)-305(as)-305(bacteria)-305(in)-305(broth)-305(cultures)-305(to)-305(reach)-305(maximal)-305(microbial)]TJ 0 -1.214 TD [(densities)-474(of)-474(10)]TJ 5.5 0 0 5.5 115.837 288.2813 Tm (8)Tj 9.5 0 0 9.5 123.093 284.5284 Tm [(to)-474(10)]TJ 5.5 0 0 5.5 144.4888 288.2813 Tm (11)Tj 9.5 0 0 9.5 154.4949 284.5284 Tm [(colony-forming)-474(units)-474(per)-474(gram)-474(of)]TJ -10.351 -1.214 Td [(vegetation)-384(within)-384(a)-384(short)-384(time)-384(on)-384(the)-384(left)-384(side)-384(of)-384(the)-384(heart,)]TJ 0 -1.214 TD [(apparently)-309(uninhibited)-309(by)-309(host)-309(defenses)-309(in)-309(left-sided)-309(lesions.)]TJ 0 -1.214 TD [(Right-sided)-268(vegetations)-268(have)-268(lower)-268(bacterial)-268(densities,)-268(which)]TJ 0 -1.214 TD [(may)-225(be)-225(the)-225(consequence)-225(of)-225(host)-225(defense)-225(mechanisms)-225(active)-225(at)]TJ T* [(this)-563(site,)-563(such)-563(as)-563(polymorphonuclear)-563(activity)-563(or)-563(platelet-)]TJ T* [(derived)-347(antibacterial)-347(proteins.)-347(More)-347(than)-347(90%)-347(of)-347(the)-347(micro-)]TJ T* [(organisms)-329(in)-329(mature)-329(left-)-329(or)-329(right-sided)-329(valvular)-329(vegetations)]TJ T* [(are)-475(metabolically)-475(inactive)-475(rather)-475(than)-475(in)-475(an)-475(active)-475(growth)]TJ T* [(phase)-455(and)-455(are)-455(therefore)-455(less)-455(responsive)-455(to)-455(the)-455(bactericidal)]TJ T* [(effects)-333(of)-333(antibiotics.)]TJ 6.5 0 0 5.5 137.6773 171.7216 Tm (20)Tj /T1_1 1 Tf 11.5 0 0 11.5 66.1761 146.1563 Tm [(Rationale)-333(for)-333(or)-333(Against)-333(Prophylaxis)-333(of)-333(IE)]TJ 10.5 0 0 10.5 56.1648 130.6222 Tm [(Historical)-333(Background)]TJ /T1_0 1 Tf 9.5 0 0 9.5 56.1648 119.5881 Tm [(Viridans)-293(group)-293(streptococci)-293(are)-293(part)-293(of)-293(the)-293(normal)-293(skin,)-293(oral,)]TJ 0 -1.214 TD [(respiratory,)-275(and)-275(GI)-275(tract)-275(flora,)-275(and)-275(they)-275(cause)-275(at)-275(least)-275(50%)-275(of)]TJ T* [(cases)-345(of)-345(community-acquired)-345(native)-345(valve)-345(IE)-345(not)-345(associated)]TJ 0 -1.214 TD [(with)-229(intravenous)-229(drug)-229(use.)]TJ 6.5 0 0 5.5 156.3499 87.5171 Tm (21)Tj 9.5 0 0 9.5 165.0234 84.9859 Tm [(More)-229(than)-229(a)-229(century)-229(ago,)-229(the)-229(oral)]TJ -11.459 -1.214 Td [(cavity)-268(was)-268(recognized)-268(as)-268(a)-268(potential)-268(source)-268(of)-268(the)-268(bacteremia)]TJ 0 -1.214 TD [(that)-307(caused)-307(viridans)-307(group)-307(streptococcal)-307(IE.)-307(In)-307(1885,)-307(Osler)]TJ 6.5 0 0 5.5 283.675 64.4489 Tm (22)Tj 9.5 0 0 9.5 56.1648 50.3835 Tm [(noted)-416(an)-416(association)-416(between)-416(bacteremia)-416(from)-416(surgery)-416(and)]TJ 27.158 70.474 Td [(IE.)-320(Okell)-320(and)-320(Elliott)]TJ 6.5 0 0 5.5 393.2185 722.4148 Tm (23)Tj 9.5 0 0 9.5 402.7614 719.8835 Tm [(in)-320(1935)-320(reported)-320(that)-320(11%)-320(of)-320(patients)]TJ -9.326 -1.231 Td [(with)-559(poor)-559(oral)-559(hygiene)-559(had)-559(positive)-559(blood)-559(cultures)-559(with)]TJ 0 -1.231 TD [(viridans)-510(group)-510(streptococci)-510(and)-510(that)-510(61%)-510(of)-510(patients)-510(had)]TJ 0.038 Tc 0 -1.231 TD [(viridans)-697(group)-697(streptococcal)-697(bacteremia)-697(with)-697(dental)]TJ 0 Tc 0 -1.231 TD (extraction.)Tj 1 -1.231 Td [(As)-364(a)-364(result)-364(of)-364(these)-364(early)-364(studies)-364(and)-364(subsequent)-364(studies,)]TJ -1 -1.231 Td [(during)-333(the)-333(past)-333(50)-333(years,)-333(the)-333(AHA)-333(guidelines)-333(recommended)]TJ 0 -1.231 TD [(antimicrobial)-599(prophylaxis)-599(to)-599(prevent)-599(IE)-599(in)-599(patients)-599(with)]TJ 0 -1.231 TD [(underlying)-517(cardiac)-517(conditions)-517(who)-517(underwent)-517(bacteremia-)]TJ T* [(producing)-378(procedures)-378(on)-378(the)-378(basis)-378(of)-378(the)-378(following)-378(factors:)]TJ T* [(\(1\))-329(bacteremia)-329(causes)-329(endocarditis;)-329(\(2\))-329(viridans)-329(group)-329(strep-)]TJ T* [(tococci)-311(are)-311(part)-311(of)-311(the)-311(normal)-311(oral)-311(flora,)-311(and)-311(enterococci)-311(are)]TJ T* [(part)-326(of)-326(the)-326(normal)-326(GI)-326(and)-326(GU)-326(tract)-326(flora;)-326(\(3\))-326(these)-326(microor-)]TJ T* [(ganisms)-245(were)-245(usually)-245(susceptible)-245(to)-245(antibiotics)-245(recommended)]TJ 0 -1.231 TD [(for)-365(prophylaxis;)-365(\(4\))-365(antibiotic)-365(prophylaxis)-365(prevents)-365(viridans)]TJ T* [(group)-328(streptococcal)-328(or)-328(enterococcal)-328(experimental)-328(endocardi-)]TJ T* [(tis)-280(in)-280(animals;)-280(\(5\))-280(a)-280(large)-280(number)-280(of)-280(poorly)-280(documented)-280(case)]TJ T* [(reports)-295(implicated)-295(a)-295(dental)-295(procedure)-295(as)-295(a)-295(cause)-295(of)-295(IE;)-295(\(6\))-295(in)]TJ T* [(some)-514(cases,)-514(there)-514(was)-514(a)-514(temporal)-514(relationship)-514(between)-514(a)]TJ T* [(dental)-430(procedure)-430(and)-430(the)-430(onset)-430(of)-430(symptoms)-430(of)-430(IE;)-430(\(7\))-430(an)]TJ T* [(awareness)-425(of)-425(bacteremia)-425(caused)-425(by)-425(viridans)-425(group)-425(strepto-)]TJ T* [(cocci)-247(associated)-247(with)-247(a)-247(dental)-247(procedure)-247(exists;)-247(\(8\))-247(the)-247(risk)-247(of)]TJ T* [(significant)-484(adverse)-484(reactions)-484(to)-484(an)-484(antibiotic)-484(is)-484(low)-484(in)-484(an)]TJ T* [(individual)-378(patient;)-378(and)-378(\(9\))-378(morbidity)-378(and)-378(mortality)-378(from)-378(IE)]TJ T* [(are)-277(high.)-277(Most)-277(of)-277(these)-277(factors)-277(remain)-277(valid,)-277(but)-277(collectively,)]TJ T* [(they)-397(do)-397(not)-397(compensate)-397(for)-397(the)-397(lack)-397(of)-397(published)-397(data)-397(that)]TJ T* [(demonstrate)-333(a)-333(benefit)-333(from)-333(prophylaxis.)]TJ /T1_1 1 Tf 10.5 0 0 10.5 314.1648 393.6676 Tm [(Bacteremia-Producing)-333(Dental)-333(Procedures)]TJ /T1_0 1 Tf 9.5 0 0 9.5 314.1648 382.4745 Tm [(The)-524(large)-524(majority)-524(of)-524(published)-524(studies)-524(have)-524(focused)-524(on)]TJ 0 -1.23 TD [(dental)-245(procedures)-245(as)-245(a)-245(cause)-245(of)-245(IE)-245(and)-245(the)-245(use)-245(of)-245(prophylactic)]TJ T* [(antibiotics)-283(to)-283(prevent)-283(IE)-283(in)-283(patients)-283(at)-283(risk.)-283(Few)-283(data)-283(exist)-283(on)]TJ T* [(the)-377(risk)-377(of)-377(or)-377(prevention)-377(of)-377(IE)-377(associated)-377(with)-377(a)-377(GI)-377(or)-377(GU)]TJ T* [(tract)-532(procedure.)-532(Accordingly,)-532(the)-532(Committee)-532(undertook)-532(a)]TJ 0 -1.23 TD [(critical)-583(analysis)-583(of)-583(published)-583(data)-583(in)-583(the)-583(context)-583(of)-583(the)]TJ T* [(historical)-350(rationale)-350(for)-350(recommending)-350(antibiotic)-350(prophylaxis)]TJ T* [(for)-303(IE)-303(before)-303(a)-303(dental)-303(procedure.)-303(The)-303(following)-303(factors)-303(were)]TJ T* [(considered:)-254(\(1\))-254(frequency,)-254(nature,)-254(magnitude,)-254(and)-254(duration)-254(of)]TJ T* [(bacteremia)-361(associated)-361(with)-361(dental)-361(procedures;)-361(\(2\))-361(impact)-361(of)]TJ T* [(dental)-293(disease,)-293(oral)-293(hygiene,)-293(and)-293(type)-293(of)-293(dental)-293(procedure)-293(on)]TJ T* [(bacteremia;)-361(\(3\))-361(impact)-361(of)-361(antibiotic)-361(prophylaxis)-361(on)-361(bactere-)]TJ T* [(mia)-303(from)-303(a)-303(dental)-303(procedure;)-303(and)-303(\(4\))-303(the)-303(exposure)-303(over)-303(time)]TJ T* [(of)-345(frequently)-345(occurring)-345(bacteremia)-345(from)-345(routine)-345(daily)-345(activ-)]TJ 0.032 Tc 0 -1.23 TD [(ities)-691(compared)-691(with)-691(bacteremia)-691(from)-691(various)-691(dental)]TJ 0 Tc T* (procedures.)Tj /T1_2 1 Tf 0 -2.019 TD [(Frequency,)-333(Nature,)-333(Magnitude,)-333(and)-333(Duration)-333(of)]TJ 0 -1.124 TD [(Bacteremia)-333(Associated)-333(With)-333(a)-333(Dental)-333(Procedure)]TJ /T1_0 1 Tf 0 -1.072 TD [(Transient)-456(bacteremia)-456(is)-456(common)-456(with)-456(manipulation)-456(of)-456(the)]TJ 0 -1.23 TD [(teeth)-294(and)-294(periodontal)-294(tissues,)-294(and)-294(there)-294(is)-294(a)-294(wide)-294(variation)-294(in)]TJ T* [(reported)-306(frequencies)-306(of)-306(bacteremia)-306(in)-306(patients)-306(resulting)-306(from)]TJ T* [(dental)-246(procedures:)-246(tooth)-246(extraction)-246(\(10%)-246(to)-246(100%\),)-246(periodon-)]TJ T* [(tal)-394(surgery)-394(\(36%)-394(to)-394(88%\),)-394(scaling)-394(and)-394(root)-394(planing)-394(\(8%)-394(to)]TJ T* [(80%\),)-316(teeth)-316(cleaning)-316(\(up)-316(to)-316(40%\),)-316(rubber)-316(dam)-316(matrix/wedge)]TJ T* [(placement)-410(\(9%)-410(to)-410(32%\),)-410(and)-410(endodontic)-410(procedures)-410(\(up)-410(to)]TJ T* (20%\).)Tj 6.5 0 0 5.5 337.1156 87.9602 Tm [(24)-120(\22630)]TJ 9.5 0 0 9.5 356.2327 85.429 Tm [(Transient)-220(bacteremia)-220(also)-220(occurs)-220(frequently)-220(during)]TJ -4.428 -1.23 Td [(routine)-340(daily)-340(activities)-340(unrelated)-340(to)-340(a)-340(dental)-340(procedure,)-340(such)]TJ 0 -1.23 TD [(as)-294(tooth)-294(brushing)-294(and)-294(flossing)-294(\(20%)-294(to)-294(68%\),)-294(use)-294(of)-294(wooden)]TJ T* [(toothpicks)-259(\(20%)-259(to)-259(40%\),)-259(use)-259(of)-259(water)-259(irrigation)-259(devices)-259(\(7%)]TJ /T1_1 1 Tf 10 0 0 10 293.7926 752.3835 Tm [(Wilson)-333(et)-333(al)-2000(Prevention)-333(of)-333(Infective)-333(Endocarditis)]TJ /T1_2 1 Tf 24.941 0 Td (5)Tj 0 g ET /GS1 gs BT /T1_3 1 Tf 9 0 0 9 294.7364 32 Tm ( by WARREN WALSH on April 19, 2007 )Tj 0 0 1 rg ET /GS1 gs BT /T1_3 1 Tf 9 0 0 9 223.2585 32 Tm (circ.ahajournals.org)Tj 0 g ET /GS1 gs BT /T1_3 1 Tf 9 0 0 9 155.2727 32 Tm (Downloaded from )Tj ET endstream endobj 227 0 obj<> endobj 228 0 obj<> endobj 229 0 obj[227 0 R] endobj 230 0 obj<> endobj 233 0 obj<>stream q 360 0 0 139 129 259 cm /Im0 Do Q 0 0 0 1 k 1 i /GS0 gs BT /T1_0 1 Tf 0 Tc 0 Tw 0 Ts 100 Tz 0 Tr 9.5 0 0 9.5 56.1648 719.8835 Tm [(to)-287(50%\),)-287(and)-287(chewing)-287(food)-287(\(7%)-287(to)-287(51%\).)]TJ 6.5 0 0 5.5 215.079 722.4148 Tm [(26)-120(\22629,31\22636)]TJ 9.5 0 0 9.5 252.711 719.8835 Tm (Consider-)Tj -20.689 -1.215 Td [(ing)-408(that)-408(the)-408(average)-408(person)-408(living)-408(in)-408(the)-408(United)-408(States)-408(has)]TJ 0 -1.215 TD [(fewer)-306(than)-306(2)-306(dental)-306(visits)-306(per)-306(year,)-306(the)-306(frequency)-306(of)-306(bactere-)]TJ 0 -1.215 TD [(mia)-333(from)-333(routine)-333(daily)-333(activities)-333(is)-333(far)-333(greater.)]TJ 1 -1.215 Td [(There)-337(has)-337(been)-337(a)-337(disproportionate)-337(focus)-337(on)-337(the)-337(frequency)]TJ -1 -1.215 Td [(of)-377(bacteremia)-377(associated)-377(with)-377(dental)-377(procedures)-377(rather)-377(than)]TJ 0 -1.215 TD [(on)-493(the)-493(species)-493(of)-493(bacteria)-493(recovered)-493(from)-493(blood)-493(cultures.)]TJ T* [(Studies)-597(suggest)-597(that)-597(more)-597(than)-597(700)-597(species)-597(of)-597(bacteria,)]TJ 0 -1.215 TD [(including)-458(aerobic)-458(and)-458(anaerobic)-458(Gram-positive)-458(and)-458(Gram-)]TJ T* [(negative)-476(microorganisms,)-476(may)-476(be)-476(identified)-476(in)-476(the)-476(human)]TJ T* [(mouth,)-395(particularly)-395(on)-395(the)-395(teeth)-395(and)-395(in)-395(the)-395(gingival)-395(crevic-)]TJ T* (es.)Tj 6.5 0 0 5.5 66.4527 595.4148 Tm [(24,37\226)-120(40)]TJ 9.5 0 0 9.5 96.0474 592.8835 Tm [(Approximately)-467(30%)-467(of)-467(the)-467(flora)-467(of)-467(the)-467(gingival)]TJ -4.198 -1.215 Td [(crevice)-329(is)-329(streptococci,)-329(predominantly)-329(of)-329(the)-329(viridans)-329(group.)]TJ 0 -1.215 TD [(Of)-367(the)-367(more)-367(than)-367(100)-367(oral)-367(bacterial)-367(species)-367(recovered)-367(from)]TJ 0 -1.215 TD [(blood)-271(cultures)-271(after)-271(dental)-271(procedures,)-271(the)-271(most)-271(prevalent)-271(are)]TJ 0 -1.215 TD [(viridans)-351(group)-351(streptococci,)-351(the)-351(most)-351(common)-351(microbiolog-)]TJ T* [(ical)-295(cause)-295(of)-295(community-acquired)-295(native)-295(valve)-295(IE)-295(in)-295(non\226in-)]TJ T* [(travenous)-359(drug)-359(users.)]TJ 6.5 0 0 5.5 139.2317 526.1421 Tm (21)Tj 9.5 0 0 9.5 149.1439 523.6108 Tm [(In)-359(healthy)-359(mouths,)-359(a)-359(thin)-359(surface)-359(of)]TJ -9.787 -1.215 Td [(mucosal)-361(epithelium)-361(prevents)-361(potentially)-361(pathogenic)-361(bacteria)]TJ 0 -1.215 TD [(from)-285(entering)-286(the)-286(bloodstream)-285(and)-286(lymphatic)-286(system.)-286(Anaer-)]TJ 0 -1.215 TD [(obic)-227(microorganisms)-227(are)-227(commonly)-227(responsible)-227(for)-227(periodon-)]TJ 0 -1.215 TD [(tal)-427(disease)-427(and)-427(frequently)-427(enter)-427(the)-427(bloodstream)-427(but)-427(rarely)]TJ T* [(cause)-515(IE,)-515(with)-515(fewer)-515(than)-515(120)-515(cases)-515(reported.)]TJ 6.5 0 0 5.5 246.0595 468.4148 Tm (41)Tj 9.5 0 0 9.5 257.4546 465.8836 Tm (Viridans)Tj -21.188 -1.215 Td [(group)-338(streptococci)-338(are)-338(antagonistic)-338(to)-338(periodontal)-338(pathogens)]TJ 0 -1.215 TD [(and)-333(predominate)-333(in)-333(a)-333(clean,)-333(healthy)-333(mouth.)]TJ 6.5 0 0 5.5 224.9912 445.3239 Tm (42)Tj 9.5 0 0 9.5 65.6648 431.2472 Tm [(Few)-357(published)-357(studies)-357(exist)-357(on)-357(the)-357(magnitude)-357(of)-357(bactere-)]TJ -1 -1.215 Td [(mia)-327(after)-327(a)-327(dental)-327(procedure)-327(or)-327(from)-327(routine)-327(daily)-327(activities,)]TJ T* [(and)-382(most)-382(of)-382(the)-382(published)-382(data)-382(used)-382(older,)-382(often)-382(unreliable)]TJ 0 -1.215 TD [(microbiological)-444(methodology.)-444(There)-444(are)-444(no)-444(published)-444(data)]TJ 0 -1.215 TD [(that)-547(demonstrate)-547(that)-547(a)-547(greater)-547(magnitude)-547(of)-547(bacteremia,)]TJ T* [(compared)-277(with)-277(a)-277(lower)-277(magnitude,)-277(is)-277(more)-277(likely)-277(to)-277(cause)-277(IE)]TJ T* [(in)-451(humans.)-451(The)-451(magnitude)-451(of)-451(bacteremia)-451(resulting)-451(from)-451(a)]TJ T* [(dental)-224(procedure)-224(is)-224(relatively)-224(low)-224(\()]TJ /T1_1 1 Tf 13.84 0 Td (\003)Tj /T1_0 1 Tf 0.833 0 Td (10)Tj 5.5 0 0 5.5 205.0551 354.179 Tm (4)Tj 9.5 0 0 9.5 209.936 350.4262 Tm [(colony-forming)-224(units)]TJ -16.186 -1.215 Td [(of)-597(bacteria)-597(per)-597(milliliter\),)-597(similar)-597(to)-597(that)-597(resulting)-597(from)]TJ T* [(routine)-427(daily)-427(activities,)-427(and)-427(is)-427(less)-427(than)-427(that)-427(used)-427(to)-427(cause)]TJ T* [(experimental)-333(IE)-333(in)-333(animals)-333(\(10)]TJ 5.5 0 0 5.5 177.0061 319.5427 Tm (6)Tj 9.5 0 0 9.5 182.924 315.7898 Tm [(to)-333(10)]TJ 5.5 0 0 5.5 202.9817 319.5427 Tm (8)Tj 9.5 0 0 9.5 208.8996 315.7898 Tm [(colony-forming)-333(units)]TJ -16.077 -1.215 Td [(of)-364(bacteria)-364(per)-364(milliliter\).)]TJ 6.5 0 0 5.5 155.4428 306.7784 Tm (20,43,44)Tj 9.5 0 0 9.5 181.6511 304.2472 Tm [(Although)-364(the)-364(infective)-364(dose)]TJ -13.209 -1.215 Td [(required)-372(to)-372(cause)-372(IE)-372(in)-372(humans)-372(is)-372(unknown,)-372(the)-372(number)-372(of)]TJ 0 -1.215 TD [(microorganisms)-337(present)-337(in)-337(blood)-337(after)-337(a)-337(dental)-337(procedure)-337(or)]TJ 0 -1.215 TD [(associated)-289(with)-289(daily)-289(activities)-289(is)-289(low.)-289(Cases)-289(of)-289(IE)-288(caused)-289(by)]TJ 0 -1.215 TD [(oral)-587(bacteria)-587(probably)-587(result)-587(from)-587(the)-587(exposures)-587(to)-587(low)]TJ T* [(inocula)-250(of)-250(bacteria)-250(in)-250(the)-250(bloodstream)-250(that)-250(result)-250(from)-250(routine)]TJ T* [(daily)-239(activities)-239(and)-239(not)-239(from)-239(a)-239(dental)-239(procedure.)-239(Additionally,)]TJ T* [(the)-386(vast)-386(majority)-386(of)-386(patients)-386(with)-386(IE)-386(have)-386(not)-386(had)-386(a)-386(dental)]TJ 0 -1.215 TD [(procedure)-379(within)-379(2)-379(weeks)-379(before)-379(the)-379(onset)-379(of)-379(symptoms)-379(of)]TJ T* (IE.)Tj 6.5 0 0 5.5 67.5072 202.8693 Tm [(2\226)-120(4)]TJ 9.5 0 0 9.5 65.6648 188.7927 Tm [(The)-341(role)-341(of)-341(duration)-341(of)-341(bacteremia)-341(on)-341(the)-341(risk)-341(of)-341(acquisi-)]TJ -1 -1.214 Td [(tion)-248(of)-248(IE)-248(is)-248(uncertain.)]TJ 6.5 0 0 5.5 141.3286 179.7898 Tm (45,46)Tj 9.5 0 0 9.5 158.3149 177.2585 Tm [(Early)-248(studies)-248(reported)-248(that)-248(sequen-)]TJ -10.753 -1.214 Td [(tial)-386(blood)-386(cultures)-386(were)-386(positive)-386(for)-386(up)-386(to)-386(10)-386(minutes)-386(after)]TJ 0 -1.214 TD [(tooth)-635(extraction)-635(and)-635(that)-635(the)-635(number)-635(of)-635(positive)-635(blood)]TJ 0 -1.214 TD [(cultures)-311(dropped)-311(sharply)-311(after)-311(10)-311(to)-311(30)-311(minutes.)]TJ 6.5 0 0 5.5 242.2711 145.1875 Tm (24,45\22651)Tj 9.5 0 0 9.5 269.6016 142.6563 Tm (More)Tj -22.467 -1.214 Td [(recent)-231(studies)-231(support)-231(these)-231(data)-231(but)-231(report)-231(a)-231(small)-231(percentage)]TJ 0 -1.214 TD [(of)-341(positive)-341(blood)-341(cultures)-341(from)-341(30)-341(to)-341(60)-341(minutes)-341(after)-341(tooth)]TJ 0 -1.214 TD (extraction.)Tj 6.5 0 0 5.5 96.5282 110.5853 Tm (43,52,53)Tj 9.5 0 0 9.5 122.8472 108.054 Tm [(Intuitively,)-376(it)-376(seems)-376(logical)-376(to)-376(assume)-376(that)]TJ -7.019 -1.214 Td [(the)-328(longer)-328(the)-328(duration)-328(of)-328(bacteremia,)-328(the)-328(greater)-328(the)-328(risk)-328(of)]TJ 0 -1.214 TD [(IE,)-350(but)-350(no)-350(published)-350(studies)-350(support)-350(this)-350(assumption.)-350(Given)]TJ 0 -1.214 TD [(the)-500(preponderance)-500(of)-500(published)-500(data,)-500(there)-500(may)-500(not)-500(be)-500(a)]TJ 0 -1.214 TD [(clinically)-606(significant)-606(difference)-606(in)-606(the)-606(frequency,)-606(nature,)]TJ T* [(magnitude,)-547(and)-547(duration)-547(of)-547(bacteremia)-547(associated)-547(with)-547(a)]TJ 27.158 70.474 Td [(dental)-385(procedure)-385(compared)-385(with)-385(that)-385(resulting)-385(from)-385(routine)]TJ 0 -1.218 TD [(daily)-289(activities.)-289(Accordingly,)-289(it)-289(is)-289(inconsistent)-289(to)-289(recommend)]TJ T* [(prophylaxis)-230(of)-230(IE)-230(for)-230(dental)-230(procedures)-230(but)-230(not)-231(for)-230(these)-230(same)]TJ T* [(patients)-325(during)-325(routine)-325(daily)-325(activities.)-325(Such)-325(a)-325(recommenda-)]TJ T* [(tion)-517(for)-517(prophylaxis)-517(for)-517(routine)-517(daily)-517(activities)-517(would)-517(be)]TJ T* [(impractical)-333(and)-333(unwarranted.)]TJ /T1_2 1 Tf 0 -2.007 TD [(Impact)-333(of)-333(Dental)-333(Disease,)-333(Oral)-333(Hygiene,)-333(and)-333(Type)-333(of)]TJ 0 -1.112 TD [(Dental)-333(Procedure)-333(on)-333(Bacteremia)]TJ /T1_0 1 Tf 0 -1.06 TD [(It)-472(is)-472(assumed)-472(that)-472(a)-472(relationship)-472(exists)-472(between)-472(poor)-472(oral)]TJ 0 -1.218 TD [(hygiene,)-244(the)-244(extent)-244(of)-244(dental)-244(and)-244(periodontal)-244(disease,)-244(the)-244(type)]TJ T* [(of)-425(dental)-425(procedure,)-425(and)-425(the)-425(frequency,)-425(nature,)-425(magnitude,)]TJ T* [(and)-326(duration)-326(of)-326(bacteremia,)-326(but)-326(the)-326(presumed)-326(relationship)-326(is)]TJ 0.0072 Tc T* (controversial.)Tj 0.0105 Tc 6.5 0 0 5.5 367.0911 578.5967 Tm [(23,29,30,38,45,54)-120(\226)-120(61)]TJ 0.0072 Tc 9.5 0 0 9.5 433.2155 576.0654 Tm [(Nevertheless,)-666(available)-666(evi-)]TJ 0 Tc -12.532 -1.218 Td [(dence)-447(supports)-447(an)-447(emphasis)-447(on)-447(maintaining)-447(good)-447(oral)-447(hy-)]TJ 0 -1.218 TD [(giene)-226(and)-226(eradicating)-226(dental)-226(disease)-226(to)-226(decrease)-226(the)-226(frequency)]TJ T* [(of)-597(bacteremia)-597(from)-597(routine)-597(daily)-597(activities.)]TJ 6.5 0 0 5.5 493.1887 543.8921 Tm [(45,56)-120(\22658,62,63)]TJ 9.5 0 0 9.5 540.2698 541.3608 Tm (In)Tj -23.8 -1.218 Td [(patients)-465(with)-465(poor)-465(oral)-465(hygiene,)-465(the)-465(frequency)-465(of)-465(positive)]TJ T* [(blood)-281(cultures)-281(just)-281(before)-281(dental)-281(extraction)-281(may)-281(be)-281(similar)-281(to)]TJ T* [(that)-333(after)-333(extraction.)]TJ 6.5 0 0 5.5 392.5045 509.1876 Tm (62,63)Tj 9.5 0 0 9.5 323.6648 495.0881 Tm [(More)-400(than)-400(80)-400(years)-400(ago,)-400(it)-400(was)-400(suggested)-400(that)-400(poor)-400(oral)]TJ -1 -1.218 Td [(hygiene)-247(and)-247(dental)-247(disease)-247(were)-247(more)-247(important)-247(as)-247(a)-247(cause)-247(of)]TJ T* [(IE)-233(than)-233(were)-233(dental)-233(procedures.)]TJ 6.5 0 0 5.5 434.055 474.483 Tm (64)Tj 9.5 0 0 9.5 442.7654 471.9517 Tm [(Most)-233(studies)-233(since)-233(that)-233(time)]TJ -13.537 -1.218 Td [(have)-420(focused)-420(instead)-420(on)-420(the)-420(risks)-420(of)-420(bacteremia)-420(associated)]TJ T* [(with)-575(dental)-575(procedures.)-575(For)-575(example,)-575(tooth)-575(extraction)-575(is)]TJ T* [(thought)-552(to)-552(be)-552(the)-552(dental)-552(procedure)-552(most)-552(likely)-552(to)-552(cause)]TJ T* [(bacteremia,)-344(with)-344(an)-344(incidence)-344(ranging)-344(from)-344(10%)-344(to)-344(100%.*)]TJ T* [(However,)-429(numerous)-429(other)-429(dental)-429(procedures)-429(have)-429(been)-429(re-)]TJ T* [(ported)-515(to)-515(be)-515(associated)-515(with)-515(risks)-515(of)-515(bacteremia)-515(that)-515(are)]TJ 0 -1.218 TD [(similar)-472(to)-472(that)-472(resulting)-472(from)-472(tooth)-472(extraction.\206)-472(A)-472(precise)]TJ 0 -1.218 TD [(determination)-399(of)-399(the)-399(relative)-399(risk)-399(of)-399(bacteremia)-399(that)-399(results)]TJ T* [(from)-349(a)-349(specific)-349(dental)-349(procedure)-349(in)-349(patients)-349(with)-349(or)-349(without)]TJ T* [(dental)-333(disease)-333(is)-333(probably)-333(not)-333(possible.)]TJ 6.5 0 0 5.5 466.3875 358.8012 Tm (27,72,73)Tj 9.5 0 0 9.5 323.6648 344.7018 Tm [(Bleeding)-246(often)-246(occurs)-246(during)-246(a)-246(dental)-246(procedure)-246(in)-246(patients)]TJ -1 -1.218 Td [(with)-436(or)-436(without)-436(periodontal)-436(disease.)-436(Previous)-436(AHA)-436(guide-)]TJ 0 -1.218 TD [(lines)-402(recommended)-402(antibiotic)-402(prophylaxis)-402(for)-402(dental)-402(proce-)]TJ T* [(dures)-398(in)-398(which)-398(bleeding)-398(was)-398(anticipated)-398(but)-398(not)-398(for)-398(proce-)]TJ T* [(dures)-335(for)-335(which)-335(bleeding)-335(was)-335(not)-335(anticipated.)]TJ 6.5 0 0 5.5 491.8461 300.9603 Tm (1)Tj 9.5 0 0 9.5 498.2838 298.429 Tm [(However,)-335(no)]TJ -19.381 -1.218 Td [(data)-264(show)-264(that)-264(visible)-264(bleeding)-264(during)-264(a)-264(dental)-264(procedure)-264(is)-264(a)]TJ T* [(reliable)-402(predictor)-402(of)-402(bacteremia.)]TJ 6.5 0 0 5.5 440.3724 277.8239 Tm (62)Tj 9.5 0 0 9.5 450.6937 275.2927 Tm [(These)-402(ambiguities)-402(in)-402(the)]TJ -14.372 -1.216 Td [(previous)-337(AHA)-337(guidelines)-337(led)-337(to)-337(further)-337(uncertainties)-337(among)]TJ 0 -1.216 TD [(healthcare)-234(providers)-234(about)-234(which)-234(dental)-234(procedures)-234(should)-234(be)]TJ T* [(covered)-333(by)-333(prophylaxis.)]TJ 1 -1.216 Td 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[(is)-255(not)-255(clear)-255(which)-255(dental)-255(procedures)-255(are)-255(more)-255(or)-255(less)-255(likely)-255(to)]TJ T* [(cause)-318(a)-318(transient)-318(bacteremia)-318(or)-318(result)-318(in)-318(a)-318(greater)-318(magnitude)]TJ T* [(of)-545(bacteremia)-545(than)-545(that)-545(which)-545(results)-545(from)-545(routine)-545(daily)]TJ T* [(activities)-333(such)-333(as)-333(chewing)-333(food,)-333(tooth)-333(brushing,)-333(or)-333(flossing.)]TJ ET 0 0 0 1 K 0.5 w 10 M 0 j 0 J []0 d 314.165 69.134 m 548.165 69.134 l S BT /T1_0 1 Tf 8 0 0 8 322.1648 59.3835 Tm [(*References)-333(23,)-333(24,)-333(27,)-333(29,)-333(45,)-333(48,)-333(52,)-333(54,)-333(57,)-333(and)-333(65\226)-120(67.)]TJ 0 -1.125 TD [(\206References)-333(27,)-333(28,)-333(47,)-333(51,)-333(54,)-333(56,)-333(58,)-333(and)-333(68)-120(\22671.)]TJ /T1_2 1 Tf 10 0 0 10 56.1648 752.3835 Tm [(6)-2000(Circulation)]TJ /T1_3 1 Tf 9.224 0 Td [(May)-333(8,)-333(2007)]TJ 0 g ET /GS1 gs BT /T1_4 1 Tf 9 0 0 9 294.7364 32 Tm ( 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[(frequency)-504(of)-504(bacteremia)-504(associated)-504(with)-504(a)-504(specific)-504(dental)]TJ T* [(procedure)-287(and)-287(the)-287(AHA)-287(guidelines)-287(for)-287(prevention)-287(of)-287(IE)-287(have)]TJ T* [(resulted)-295(in)-295(an)-295(overemphasis)-295(on)-295(antibiotic)-295(prophylaxis)-295(and)-295(an)]TJ T* [(underemphasis)-512(on)-512(maintenance)-512(of)-512(good)-512(oral)-512(hygiene)-512(and)]TJ T* [(access)-247(to)-247(routine)-247(dental)-247(care,)-247(which)-247(are)-247(likely)-247(more)-247(important)]TJ T* [(in)-319(reducing)-319(the)-319(lifetime)-319(risk)-319(of)-319(IE)-319(than)-319(the)-319(administration)-319(of)]TJ T* [(antibiotic)-416(prophylaxis)-416(for)-416(a)-416(dental)-417(procedure.)-417(However,)-417(no)]TJ T* [(observational)-333(or)-333(controlled)-333(studies)-333(support)-333(this)-333(contention.)]TJ /T1_1 1 Tf 0 -1.998 TD [(Impact)-333(of)-333(Antibiotic)-333(Therapy)-333(on)-333(Bacteremia)-333(From)-333(a)]TJ 0 -1.103 TD [(Dental)-333(Procedure)]TJ /T1_0 1 Tf 0 -1.05 TD [(The)-490(ability)-490(of)-490(antibiotic)-490(therapy)-490(to)-490(prevent)-490(or)-490(reduce)-490(the)]TJ 0 -1.208 TD [(frequency,)-403(magnitude,)-403(or)-403(duration)-403(of)-403(bacteremia)-403(associated)]TJ T* [(with)-462(a)-462(dental)-462(procedure)-462(is)-462(controversial.)]TJ 6.5 0 0 5.5 218.7368 533.7784 Tm (24,74)Tj 9.5 0 0 9.5 237.7544 531.2472 Tm [(Some)-462(studies)]TJ -19.115 -1.208 Td [(reported)-353(that)-353(antibiotics)-353(administered)-353(before)-353(a)-353(dental)-353(proce-)]TJ T* [(dure)-379(reduced)-379(the)-379(frequency,)-379(nature,)-379(and/or)-379(duration)-379(of)-379(bac-)]TJ T* (teremia,)Tj 6.5 0 0 5.5 87.0287 499.3466 Tm (53,75,76)Tj 9.5 0 0 9.5 112.4045 496.8154 Tm [(whereas)-276(others)-276(did)-276(not.)]TJ 6.5 0 0 5.5 201.2724 499.3466 Tm (24,66,77,78)Tj 9.5 0 0 9.5 234.7735 496.8154 Tm [(Recent)-276(studies)]TJ -18.801 -1.208 Td [(suggest)-289(that)-289(amoxicillin)-289(therapy)-289(has)-289(a)-289(statistically)-289(significant)]TJ T* [(impact)-469(on)-469(reducing)-469(the)-469(incidence,)-469(nature,)-469(and)-469(duration)-469(of)]TJ T* [(bacteremia)-319(from)-319(dental)-319(procedures,)-319(but)-319(it)-319(does)-319(not)-319(eliminate)]TJ T* (bacteremia.)Tj 6.5 0 0 5.5 100.214 453.4376 Tm (52,53,76)Tj 9.5 0 0 9.5 126.0245 450.9063 Tm [(However,)-322(no)-322(data)-322(show)-322(that)-322(such)-322(a)-322(reduc-)]TJ -7.354 -1.208 Td [(tion)-341(as)-341(a)-341(result)-341(of)-341(amoxicillin)-341(therapy)-341(reduces)-341(the)-341(risk)-341(of)-341(or)]TJ T* [(prevents)-276(IE.)-276(Hall)-276(et)-276(al)]TJ 6.5 0 0 5.5 140.2556 430.483 Tm (78)Tj 9.5 0 0 9.5 149.378 427.9518 Tm [(reported)-276(that)-276(neither)-276(penicillin)-276(V)-276(nor)]TJ -9.812 -1.208 Td [(amoxicillin)-361(therapy)-361(was)-361(effective)-361(in)-361(reducing)-361(the)-361(frequency)]TJ T* [(of)-405(bacteremia)-405(compared)-405(with)-405(untreated)-405(control)-405(subjects.)-405(In)]TJ T* [(patients)-547(who)-547(underwent)-547(a)-547(dental)-547(extraction,)-547(penicillin)-547(or)]TJ T* [(ampicillin)-513(therapy)-513(compared)-513(with)-513(placebo)-513(diminished)-513(the)]TJ T* [(percentage)-409(of)-409(viridans)-409(group)-409(streptococci)-409(and)-409(anaerobes)-409(in)]TJ T* [(culture,)-247(but)-247(there)-247(was)-247(no)-247(significant)-247(difference)-247(in)-247(the)-247(percent-)]TJ 0 -1.209 TD [(age)-348(of)-348(patients)-348(with)-348(positive)-348(cultures)-348(10)-348(minutes)-348(after)-348(tooth)]TJ T* (extraction.)Tj 6.5 0 0 5.5 96.5282 338.6421 Tm (24,66)Tj 9.5 0 0 9.5 114.5231 336.1108 Tm [(In)-355(a)-355(separate)-355(study,)-355(Hall)-355(et)-355(al)]TJ 6.5 0 0 5.5 231.026 338.6421 Tm (77)Tj 9.5 0 0 9.5 240.8956 336.1108 Tm [(reported)-355(that)]TJ -19.445 -1.209 Td [(cefaclor-treated)-302(patients)-302(did)-302(not)-302(have)-302(a)-302(reduction)-302(of)-302(postpro-)]TJ 0 -1.209 TD [(cedure)-306(bacteremia)-306(compared)-306(with)-306(untreated)-306(control)-306(subjects.)]TJ T* [(Contradictory)-250(published)-250(results)-250(from)-250(2)-250(studies)-250(showed)-250(reduc-)]TJ T* [(tion)-414(of)-414(postprocedure)-414(bacteremia)-414(by)-414(erythromycin)-414(in)-414(one)]TJ 6.5 0 0 5.5 283.6617 292.6875 Tm (75)Tj 9.5 0 0 9.5 56.1648 278.6677 Tm [(but)-566(lack)-566(of)-566(efficacy)-566(for)-566(erythromycin)-566(or)-566(clindamycin)-566(in)]TJ T* (another.)Tj 6.5 0 0 5.5 87.0287 269.7103 Tm (78)Tj 9.5 0 0 9.5 96.0488 267.179 Tm [(Finally,)-265(results)-265(are)-265(contradictory)-265(with)-265(regard)-265(to)-265(the)]TJ -4.198 -1.209 Td [(efficacy)-528(of)-528(the)-528(use)-528(of)-528(topical)-528(antiseptics)-528(in)-528(reducing)-528(the)]TJ T* [(frequency)-408(of)-408(bacteremia)-408(associated)-408(with)-408(dental)-408(procedures,)]TJ T* [(but)-367(the)-367(preponderance)-367(of)-367(evidence)-367(suggests)-367(that)-367(there)-367(is)-367(no)]TJ T* [(clear)-579(benefit.)-579(One)-579(study)-579(reported)-579(that)-579(chlorhexidine)-579(and)]TJ T* [(povidone)-259(iodine)-259(mouth)-259(rinse)-259(were)-259(effective,)]TJ 6.5 0 0 5.5 224.4098 212.2671 Tm (79)Tj 9.5 0 0 9.5 233.3759 209.7358 Tm [(whereas)-260(others)]TJ -18.654 -1.209 Td [(showed)-391(no)-391(statistically)-391(significant)-391(benefit.)]TJ 6.5 0 0 5.5 221.6907 200.7784 Tm (52,80)Tj 9.5 0 0 9.5 240.0321 198.2472 Tm [(Topical)-391(anti-)]TJ -19.355 -1.209 Td [(septic)-236(rinses)-236(do)-236(not)-236(penetrate)-236(beyond)-236(3)-236(mm)-236(into)-236(the)-236(periodon-)]TJ T* [(tal)-264(pocket)-264(and)-264(therefore)-264(do)-264(not)-264(reach)-264(areas)-264(of)-264(ulcerated)-264(tissue)]TJ T* [(where)-241(bacteria)-241(most)-241(often)-241(gain)-241(entrance)-241(to)-241(the)-241(circulation.)-241(On)]TJ T* [(the)-222(basis)-222(of)-222(these)-222(data,)-222(it)-222(is)-222(unlikely)-222(that)-222(topical)-222(antiseptics)-222(are)]TJ T* [(effective)-458(to)-458(significantly)-458(reduce)-458(the)-458(frequency,)-458(magnitude,)]TJ 0.0248 Tc T* [(and)-684(duration)-684(of)-684(bacteremia)-684(associated)-684(with)-684(a)-684(dental)]TJ 0 Tc 0 -1.209 TD (procedure.)Tj /T1_2 1 Tf -0.0398 Tc 10.5 0 0 10.5 56.1648 95.8381 Tm [(Cumulative)-293(Risk)-293(Over)-293(Time)-293(of)-293(Bacteremias)-293(From)]TJ 0 -1.094 TD [(Routine)-293(Daily)-293(Activities)-293(Compared)-293(With)-293(the)]TJ T* [(Bacteremia)-293(From)-293(a)-293(Dental)-293(Procedure)]TJ /T1_0 1 Tf 0 Tc 9.5 0 0 9.5 56.1648 61.8722 Tm (Guntheroth)Tj 6.5 0 0 5.5 99.435 64.4034 Tm (81)Tj 9.5 0 0 9.5 109.1114 61.8722 Tm [(estimated)-334(a)-334(cumulative)-334(exposure)-334(of)-334(5370)-334(min-)]TJ -5.573 -1.209 Td [(utes)-621(of)-621(bacteremia)-621(over)-621(a)-621(1-month)-621(period)-621(in)-621(dentulous)]TJ 27.158 70.474 Td [(patients)-551(resulting)-551(from)-551(random)-551(bacteremia)-551(from)-551(chewing)]TJ 0 -1.219 TD [(food)-277(and)-277(from)-277(oral)-277(hygiene)-277(measures,)-277(such)-277(as)-277(tooth)-277(brushing)]TJ T* [(and)-234(flossing,)-234(and)-234(compared)-234(that)-234(with)-234(a)-234(duration)-234(of)-234(bacteremia)]TJ T* [(lasting)-638(6)-638(to)-638(30)-638(minutes)-638(associated)-638(with)-638(a)-638(single)-638(tooth)]TJ T* [(extraction.)-434(Roberts)]TJ 6.5 0 0 5.5 388.2005 676.0967 Tm (62)Tj 9.5 0 0 9.5 398.8201 673.5654 Tm [(estimated)-434(that)-434(tooth)-434(brushing)-434(2)-434(times)]TJ -8.911 -1.219 Td [(daily)-293(for)-293(1)-293(year)-293(had)-293(a)-293(154)-250(000)-293(times)-293(greater)-293(risk)-293(of)-293(exposure)]TJ 0 -1.219 TD [(to)-349(bacteremia)-349(than)-349(that)-349(resulting)-349(from)-349(a)-349(single)-349(tooth)-349(extrac-)]TJ 0 -1.219 TD [(tion.)-402(The)-402(cumulative)-402(exposure)-402(during)-402(1)-402(year)-402(to)-402(bacteremia)]TJ 0 -1.219 TD [(from)-399(routine)-399(daily)-399(activities)-399(may)-399(be)-399(as)-399(high)-399(as)-399(5.6)-399(million)]TJ T* [(times)-373(greater)-373(than)-373(that)-373(resulting)-373(from)-373(a)-373(single)-373(tooth)-373(extrac-)]TJ T* [(tion,)-289(the)-289(dental)-289(procedure)-289(reported)-289(to)-289(be)-289(most)-289(likely)-288(to)-289(cause)]TJ 0 -1.218 TD [(a)-333(bacteremia.)]TJ 6.5 0 0 5.5 365.5937 595.0512 Tm (62)Tj 9.5 0 0 9.5 323.6648 580.9518 Tm [(Data)-460(exist)-460(for)-460(the)-460(duration)-460(of)-460(bacteremia)-460(from)-460(a)-460(single)]TJ -1 -1.218 Td [(tooth)-487(extraction,)-487(and)-487(it)-487(is)-487(possible)-487(to)-487(estimate)-487(the)-487(annual)]TJ T* [(cumulative)-329(exposure)-329(from)-329(dental)-329(procedures)-329(for)-329(the)-329(average)]TJ T* [(individual.)-403(However,)-403(calculations)-403(for)-403(the)-403(incidence,)-403(nature,)]TJ T* [(and)-256(duration)-256(of)-256(bacteremia)-256(from)-256(routine)-256(daily)-256(activities)-256(are)-256(at)]TJ T* [(best)-568(rough)-568(estimates,)-568(and)-568(it)-568(is)-568(therefore)-568(not)-568(possible)-568(to)]TJ T* [(compare)-250(precisely)-250(the)-250(cumulative)-250(monthly)-250(or)-250(annual)-250(duration)]TJ 0 -1.218 TD [(of)-274(exposure)-274(for)-274(bacteremia)-274(from)-274(dental)-274(procedures)-274(compared)]TJ 0 -1.218 TD [(with)-413(routine)-413(daily)-413(activities.)-413(Nevertheless,)-413(even)-413(if)-413(the)-413(esti-)]TJ T* [(mates)-286(of)-286(bacteremia)-286(from)-286(routine)-286(daily)-286(activities)-286(are)-286(off)-286(by)-286(a)]TJ T* [(factor)-311(of)-311(1000,)-311(it)-311(is)-311(likely)-311(that)-311(the)-311(frequency)-311(and)-311(cumulative)]TJ T* [(duration)-295(of)-295(exposure)-295(to)-295(bacteremia)-295(from)-295(routine)-295(daily)-295(events)]TJ T* [(over)-245(1)-245(year)-245(are)-245(much)-245(higher)-245(than)-245(those)-245(that)-245(result)-245(from)-245(dental)]TJ T* (procedures.)Tj /T1_2 1 Tf 10.5 0 0 10.5 314.1648 408.4972 Tm [(Results)-333(of)-333(Clinical)-333(Studies)-333(of)-333(IE)-333(Prophylaxis)-333(for)]TJ 0 -1.102 TD [(Dental)-333(Procedures)]TJ /T1_0 1 Tf 9.5 0 0 9.5 314.1648 385.8608 Tm [(No)-283(prospective,)-283(randomized,)-283(placebo-controlled)-283(studies)-283(exist)]TJ 0 -1.218 TD [(on)-484(the)-484(efficacy)-484(of)-484(antibiotic)-484(prophylaxis)-484(to)-484(prevent)-484(IE)-484(in)]TJ T* [(patients)-465(who)-465(undergo)-465(a)-465(dental)-465(procedure.)-465(Data)-465(from)-465(pub-)]TJ T* [(lished)-458(retrospective)-458(or)-458(prospective)-458(case-control)-458(studies)-458(are)]TJ T* [(limited)-294(by)-294(the)-294(following)-294(factors:)-294(\(1\))-294(the)-294(low)-294(incidence)-294(of)-294(IE,)]TJ T* [(which)-503(requires)-503(a)-503(large)-503(number)-503(of)-503(patients)-503(per)-503(cohort)-503(for)]TJ T* [(statistical)-256(significance;)-256(\(2\))-256(the)-256(wide)-256(variation)-256(in)-256(the)-256(types)-256(and)]TJ 0 -1.218 TD [(severity)-420(of)-420(underlying)-420(cardiac)-420(conditions,)-420(which)-420(would)-420(re-)]TJ 0 -1.218 TD [(quire)-225(a)-225(large)-225(number)-225(of)-225(patients)-225(with)-225(specific)-225(matched)-225(control)]TJ T* [(subjects)-318(for)-318(each)-318(cardiac)-318(condition;)-318(and)-318(\(3\))-318(the)-318(large)-318(variety)]TJ T* [(of)-243(invasive)-243(dental)-243(procedures)-243(and)-243(dental)-243(disease)-243(states,)-243(which)]TJ T* 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[(valve)-417(replacement)-417(surgery,)-417(perivalvular)-417(extension)-417(of)-417(infec-)]TJ 0 -1.233 TD [(tion,)-333(and)-333(other)-333(complications.)]TJ 1 -1.233 Td [(Patients)-259(with)-259(relapsing)-259(or)-259(recurrent)-259(IE)-259(are)-259(at)-259(greater)-259(risk)-259(of)]TJ -1 -1.233 Td [(congestive)-302(heart)-302(failure)-302(and)-302(increased)-302(need)-302(for)-302(cardiac)-302(valve)]TJ 0 -1.233 TD [(replacement)-410(surgery,)-410(and)-410(they)-410(have)-410(a)-410(higher)-410(mortality)-410(rate)]TJ 0 -1.233 TD [(than)-422(patients)-422(with)-422(a)-422(first)-422(episode)-422(of)-422(native)-422(valve)-422(IE.)]TJ 6.5 0 0 5.5 266.6335 123.2103 Tm [(118)-120(\226124)]TJ 9.5 0 0 9.5 56.1648 108.9631 Tm [(Additionally,)-507(patients)-507(with)-507(multiple)-507(episodes)-507(of)-507(native)-507(or)]TJ T* [(prosthetic)-225(valve)-225(IE)-225(are)-225(at)-225(greater)-225(risk)-225(of)-225(additional)-225(episodes)-225(of)]TJ T* [(endocarditis,)-222(each)-222(of)-222(which)-222(is)-222(associated)-222(with)-222(the)-222(risk)-222(of)-222(more)]TJ T* [(serious)-333(complications.)]TJ 6.5 0 0 5.5 141.9155 76.3466 Tm (90)Tj 9.5 0 0 9.5 65.6648 62.0995 Tm [(Published)-504(series)-504(regarding)-504(endocarditis)-504(in)-504(patients)-504(with)]TJ -1 -1.233 Td [(CHD)-386(are)-386(underpowered)-386(to)-386(determine)-386(the)-386(extent)-386(to)-386(which)-386(a)]TJ 27.158 70.474 Td [(specific)-571(form)-571(of)-571(CHD)-571(is)-571(an)-571(independent)-571(risk)-571(factor)-571(for)]TJ 0 -1.219 TD [(morbidity)-561(and)-561(mortality.)-561(Nevertheless,)-561(most)-561(retrospective)]TJ T* [(case)-302(series)-302(suggest)-302(that)-302(patients)-302(with)-302(complex)-302(cyanotic)-302(heart)]TJ T* [(disease)-381(and)-381(those)-381(who)-381(have)-381(postoperative)-381(palliative)-381(shunts,)]TJ T* [(conduits,)-487(or)-487(other)-487(prostheses)-487(have)-487(a)-487(high)-487(lifetime)-487(risk)-487(of)]TJ 0 -1.219 TD [(acquiring)-244(IE,)-244(and)-244(these)-244(same)-244(groups)-244(appear)-244(at)-244(highest)-244(risk)-244(for)]TJ T* [(morbidity)-316(and)-316(mortality)-316(among)-316(all)-316(patients)-316(with)-316(CHD.)]TJ 6.5 0 0 5.5 525.4409 652.9376 Tm (125\226129)Tj 9.5 0 0 9.5 314.1648 638.8268 Tm [(In)-507(addition,)-507(multiple)-507(series)-507(and)-507(reviews)-507(reported)-507(that)-507(the)]TJ 0 -1.219 TD [(presence)-430(of)-430(prosthetic)-430(material)]TJ 6.5 0 0 5.5 436.1674 629.7784 Tm (130,131)Tj 9.5 0 0 9.5 461.3812 627.2472 Tm [(and)-430(complex)-430(cyanotic)]TJ -15.497 -1.219 Td [(heart)-410(disease)-410(in)-410(patients)-410(of)-410(very)-410(young)-410(age)-410(\(newborns)-410(and)]TJ T* (infants)Tj /T1_1 1 Tf 3.095 0 Td (\003)Tj /T1_0 1 Tf 0.833 0 Td [(2)-373(years)-373(of)-373(age\))]TJ 6.5 0 0 5.5 411.1842 606.6194 Tm (132,133)Tj 9.5 0 0 9.5 435.8583 604.0881 Tm [(are)-373(2)-373(factors)-373(associated)-373(with)]TJ -12.81 -1.218 Td [(the)-400(worst)-400(prognoses)-400(from)-400(IE.)-400(Some)-400(types)-400(of)-400(CHD)-400(may)-400(be)]TJ 0 -1.218 TD [(repaired)-602(completely)-602(without)-602(residual)-602(cardiac)-602(defects.)-602(As)]TJ T* [(shown)-388(in)-388(Table)-388(3,)-388(the)-388(Committee)-388(recommends)-388(prophylaxis)]TJ T* [(for)-484(dental)-484(procedures)-484(for)-484(these)-484(patients)-484(during)-484(the)-484(first)-484(6)]TJ T* [(months)-583(after)-583(the)-583(procedure.)-583(In)-583(these)-583(patients,)-583(endotheli-)]TJ T* [(alization)-455(of)-455(prosthetic)-455(material)-455(or)-455(devices)-455(occurs)-455(within)-455(6)]TJ 0 -1.218 TD [(months)-607(after)-607(the)-607(procedure.)]TJ 6.5 0 0 5.5 428.8074 525.6421 Tm (134)Tj 9.5 0 0 9.5 444.3248 523.1108 Tm [(The)-607(Committee)-607(does)-607(not)]TJ -13.701 -1.218 Td [(recommend)-416(prophylaxis)-416(for)-417(dental)-417(procedures)-416(more)-416(than)-416(6)]TJ 0 -1.218 TD 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[(In)-514(a)-514(major)-514(departure)-514(from)-514(previous)-514(AHA)-514(guidelines,)-514(the)]TJ 0 -1.218 TD [(Committee)-597(no)-597(longer)-597(recommends)-597(IE)-597(prophylaxis)-597(based)]TJ T* [(solely)-308(on)-308(an)-308(increased)-308(lifetime)-308(risk)-308(of)-308(acquisition)-308(of)-308(IE.)-308(It)-308(is)]TJ T* [(noteworthy)-286(that)-286(patients)-286(with)-286(the)-286(conditions)-286(listed)-286(in)-286(Table)-286(3)]TJ T* [(with)-259(a)-259(prosthetic)-259(cardiac)-259(valve,)-259(those)-259(with)-259(a)-259(previous)-259(episode)]TJ T* [(of)-439(IE,)-439(and)-439(some)-439(patients)-439(with)-439(CHD)-439(are)-439(also)-439(among)-439(those)]TJ T* [(patients)-621(with)-621(the)-621(highest)-621(lifetime)-621(risk)-621(of)-621(acquisition)-621(of)]TJ 0 -1.218 TD [(endocarditis.)-522(No)-522(published)-522(data)-522(demonstrate)-522(convincingly)]TJ 0 -1.218 TD [(that)-258(the)-258(administration)-258(of)-258(prophylactic)-258(antibiotics)-258(prevents)-258(IE)]TJ T* [(associated)-357(with)-357(bacteremia)-357(from)-357(an)-357(invasive)-357(procedure.)-357(We)]TJ T* [(cannot)-361(exclude)-361(the)-361(possibility)-361(that)-361(there)-361(may)-361(be)-361(an)-361(exceed-)]TJ T* [(ingly)-275(small)-275(number)-275(of)-275(cases)-275(of)-275(IE)-275(that)-275(could)-275(be)-275(prevented)-275(by)]TJ T* [(prophylactic)-329(antibiotics)-329(in)-329(patients)-329(who)-329(undergo)-329(an)-329(invasive)]TJ T* [(procedure.)-270(However,)-270(if)-270(prophylaxis)-270(is)-270(effective,)-270(such)-270(therapy)]TJ T* [(should)-308(be)-308(restricted)-308(to)-308(those)-308(patients)-308(with)-308(the)-308(highest)-308(risk)-308(of)]TJ T* [(adverse)-524(outcome)-524(from)-524(IE)-524(who)-524(would)-524(derive)-524(the)-524(greatest)]TJ T* [(benefit)-444(from)-444(prevention)-444(of)-444(IE.)-444(In)-444(patients)-444(with)-444(underlying)]TJ T* 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[(providers)-324(and)-324(are)-324(based)-324(on)-324(the)-324(best)-324(available)-324(published)-324(data)]TJ T* [(and)-343(expert)-343(opinion.)-343(Additionally,)-343(the)-343(change)-343(in)-343(emphasis)-343(to)]TJ T* [(recommend)-575(prophylaxis)-575(for)-575(only)-575(those)-575(patients)-575(with)-575(the)]TJ T* [(highest)-288(risk)-288(of)-288(adverse)-288(outcome)-288(should)-288(reduce)-288(the)-288(uncertain-)]TJ T* [(ties)-336(among)-336(patients)-336(and)-336(providers)-336(about)-336(who)-336(should)-336(receive)]TJ /T1_4 1 Tf 9 0 0 9 56.1648 720.3835 Tm [(TABLE)-333(3.)-1000(Cardiac)-333(Conditions)-333(Associated)-333(With)-333(the)-333(Highest)-333(Risk)]TJ 0 -1.167 TD [(of)-333(Adverse)-333(Outcome)-333(From)-333(Endocarditis)-333(for)-333(Which)-333(Prophylaxis)]TJ T* [(With)-333(Dental)-333(Procedures)-333(Is)-333(Recommended)]TJ ET 0 0 0 1 K 0.75 w 10 M 0 j 0 J []0 d 56.165 693.009 m 290.165 693.009 l 56.165 570.259 m 290.165 570.259 l S BT /T1_5 1 Tf 8 0 0 8 56.1648 682.6335 Tm [(Prosthetic)-333(cardiac)-333(valve)]TJ 0 -1.625 TD [(Previous)-333(IE)]TJ T* [(Congenital)-333(heart)-333(disease)-333(\(CHD\)*)]TJ 1 -1.625 Td [(Unrepaired)-333(cyanotic)-333(CHD,)-333(including)-333(palliative)-333(shunts)-333(and)-333(conduits)]TJ T* [(Completely)-333(repaired)-333(congenital)-333(heart)-333(defect)-333(with)-333(prosthetic)-333(material)-333(or)]TJ 0 -1.25 TD [(device,)-333(whether)-333(placed)-333(by)-333(surgery)-333(or)-333(by)-333(catheter)-333(intervention,)-333(during)-333(the)]TJ T* [(first)-333(6)-333(months)-333(after)-333(the)-333(procedure\206)]TJ 0 -1.625 TD [(Repaired)-333(CHD)-333(with)-333(residual)-333(defects)-333(at)-333(the)-333(site)-333(or)-333(adjacent)-333(to)-333(the)-333(site)-333(of)-333(a)]TJ 0 -1.25 TD [(prosthetic)-333(patch)-333(or)-333(prosthetic)-333(device)-333(\(which)-333(inhibit)-333(endothelialization\))]TJ -1 -1.625 Td [(Cardiac)-333(transplantation)-333(recipients)-333(who)-333(develop)-333(cardiac)-333(valvulopathy)]TJ 1 -1.719 Td [(*Except)-368(for)-368(the)-368(conditions)-368(listed)-368(above,)-368(antibiotic)-368(prophylaxis)-368(is)-368(no)-368(longer)]TJ -1 -1.25 Td [(recommended)-333(for)-333(any)-333(other)-333(form)-333(of)-333(CHD.)]TJ 1 -1.25 Td [(\206Prophylaxis)-619(is)-619(recommended)-619(because)-619(endothelialization)-619(of)-619(prosthetic)]TJ -1 -1.25 Td [(material)-333(occurs)-333(within)-333(6)-333(months)-333(after)-333(the)-333(procedure.)]TJ /T1_3 1 Tf 10 0 0 10 56.1648 752.3835 Tm [(10)-2000(Circulation)]TJ /T1_2 1 Tf 9.724 0 Td [(May)-333(8,)-333(2007)]TJ 0 g ET /GS1 gs BT /T1_6 1 Tf 9 0 0 9 294.7364 32 Tm ( by WARREN WALSH on April 19, 2007 )Tj 0 0 1 rg ET /GS1 gs BT /T1_6 1 Tf 9 0 0 9 223.2585 32 Tm (circ.ahajournals.org)Tj 0 g ET /GS1 gs BT /T1_6 1 Tf 9 0 0 9 155.2727 32 Tm (Downloaded from )Tj ET endstream endobj 262 0 obj<> endobj 263 0 obj<> endobj 264 0 obj[262 0 R] endobj 265 0 obj<> endobj 268 0 obj<>stream q 360 0 0 139 129 259 cm /Im0 Do Q 0 0 0 1 k 1 i /GS0 gs BT /T1_0 1 Tf 0 Tc 0 Tw 0 Ts 100 Tz 0 Tr 9.5 0 0 9.5 56.1648 719.8835 Tm [(prophylaxis.)-293(MVP)-293(is)-293(the)-293(most)-293(common)-293(underlying)-293(condition)]TJ 0 -1.212 TD [(that)-398(predisposes)-398(to)-398(acquisition)-398(of)-398(IE)-398(in)-398(the)-398(Western)-398(world;)]TJ T* [(however,)-309(the)-309(absolute)-309(incidence)-309(of)-309(endocarditis)-309(is)-309(extremely)]TJ 0 -1.212 TD [(low)-287(for)-287(the)-287(entire)-287(population)-287(with)-287(MVP,)-287(and)-287(it)-287(is)-287(not)-287(usually)]TJ 0 -1.212 TD [(associated)-371(with)-371(the)-371(grave)-371(outcome)-371(associated)-371(with)-371(the)-371(con-)]TJ T* [(ditions)-521(identified)-521(in)-521(Table)-521(3.)-521(Thus,)-521(IE)-521(prophylaxis)-521(is)-521(no)]TJ T* [(longer)-333(recommended)-333(for)-333(this)-333(group)-333(of)-333(individuals.)]TJ 1 -1.212 Td [(Finally,)-230(the)-230(administration)-230(of)-230(prophylactic)-230(antibiotics)-230(is)-230(not)]TJ -1 -1.212 Td [(risk)-420(free,)-420(as)-420(discussed)-420(above.)-420(Additionally,)-420(the)-420(widespread)]TJ 0 -1.212 TD [(use)-281(of)-281(antibiotic)-281(therapy)-281(promotes)-281(the)-281(emergence)-281(of)-281(resistant)]TJ T* [(microorganisms)-452(most)-452(likely)-452(to)-452(cause)-452(endocarditis,)-452(such)-452(as)]TJ T* [(viridans)-222(group)-222(streptococci)-222(and)-222(enterococci.)-222(The)-222(frequency)-222(of)]TJ T* [(multidrug-resistant)-472(viridans)-472(group)-472(streptococci)-472(and)-472(entero-)]TJ T* [(cocci)-382(has)-382(increased)-382(dramatically)-382(during)-382(the)-382(past)-382(2)-382(decades.)]TJ 0 -1.212 TD [(This)-330(increased)-330(resistance)-330(has)-330(reduced)-330(the)-330(efficacy)-330(and)-330(num-)]TJ 0 -1.212 TD [(ber)-333(of)-333(antibiotics)-333(available)-333(for)-333(the)-333(treatment)-333(of)-333(IE.)]TJ /T1_1 1 Tf 11.5 0 0 11.5 110.8949 524.2018 Tm [(Regimens)-333(Recommended)]TJ 10.5 0 0 10.5 56.1648 508.6904 Tm [(General)-333(Principles)]TJ /T1_0 1 Tf 9.5 0 0 9.5 56.1648 497.679 Tm [(An)-468(antibiotic)-468(for)-468(prophylaxis)-468(should)-468(be)-468(administered)-468(in)-468(a)]TJ 0 -1.212 TD [(single)-244(dose)-244(before)-244(the)-244(procedure.)-244(If)-244(the)-244(dosage)-244(of)-244(antibiotic)-244(is)]TJ /T1_2 1 Tf T* (inadvertently)Tj /T1_0 1 Tf 5.888 0 Td [(not)-611(administered)-611(before)-611(the)-611(procedure,)-611(the)]TJ -5.888 -1.212 Td [(dosage)-222(may)-222(be)-222(administered)-222(up)-222(to)-222(2)-222(hours)-222(after)-222(the)-222(procedure.)]TJ 0 -1.212 TD [(However,)-437(administration)-437(of)-437(the)-437(dosage)-437(after)-437(the)-437(procedure)]TJ T* [(should)-373(be)-373(considered)-373(only)-373(when)-373(the)-373(patient)-373(did)-373(not)-373(receive)]TJ T* [(the)-278(pre-procedure)-278(dose.)-278(Some)-278(patients)-278(who)-278(are)-278(scheduled)-278(for)]TJ T* [(an)-325(invasive)-325(procedure)-325(may)-325(have)-325(a)-325(coincidental)-325(endocarditis.)]TJ 0 -1.212 TD [(The)-455(presence)-455(of)-455(fever)-455(or)-455(other)-455(manifestations)-455(of)-455(systemic)]TJ T* [(infection)-300(should)-300(alert)-300(the)-300(provider)-300(to)-300(the)-300(possibility)-300(of)-300(IE.)-300(In)]TJ T* [(these)-354(circumstances,)-354(it)-354(is)-354(important)-354(to)-354(obtain)-354(blood)-354(cultures)]TJ T* [(and)-401(other)-401(relevant)-401(tests)-401(before)-401(administration)-401(of)-401(antibiotics)]TJ T* [(intended)-254(to)-254(prevent)-254(IE.)-254(Failure)-254(to)-254(do)-254(so)-254(may)-254(result)-254(in)-254(delay)-254(in)]TJ T* [(diagnosis)-333(or)-333(treatment)-333(of)-333(a)-333(concomitant)-333(case)-333(of)-333(IE.)]TJ /T1_1 1 Tf 10.5 0 0 10.5 56.1648 326.0199 Tm [(Regimens)-333(for)-333(Dental)-333(Procedures)]TJ /T1_0 1 Tf 9.5 0 0 9.5 56.1648 315.0085 Tm [(Previous)-321(AHA)-321(guidelines)-321(on)-321(prophylaxis)-321(listed)-321(a)-321(substantial)]TJ 0 -1.212 TD [(number)-316(of)-316(dental)-316(procedures)-316(and)-316(events)-316(for)-316(which)-316(antibiotic)]TJ T* [(prophylaxis)-597(was)-597(recommended)-597(and)-597(those)-597(procedures)-597(for)]TJ 0 -1.212 TD [(which)-333(prophylaxis)-333(was)-333(not)-333(recommended.)-333(On)-333(the)-333(basis)-333(of)-333(a)]TJ 0 -1.212 TD [(critical)-317(review)-317(of)-317(the)-317(published)-317(data,)-317(it)-317(is)-317(clear)-317(that)-317(transient)]TJ T* [(viridans)-297(group)-297(streptococcal)-297(bacteremia)-297(may)-297(result)-297(from)-297(any)]TJ T* [(dental)-232(procedure)-232(that)-232(involves)-232(manipulation)-232(of)-232(the)-232(gingival)-232(or)]TJ T* [(periapical)-256(region)-256(of)-256(teeth)-256(or)-256(perforation)-256(of)-256(the)-256(oral)-256(mucosa.)-256(It)]TJ 0 -1.212 TD [(cannot)-329(be)-329(assumed)-329(that)-329(manipulation)-329(of)-329(a)-329(healthy-appearing)]TJ T* [(mouth)-329(or)-329(a)-329(minimally)-329(invasive)-329(dental)-329(procedure)-329(reduces)-329(the)]TJ T* [(likelihood)-329(of)-329(a)-329(bacteremia.)-329(Therefore,)-329(antibiotic)-329(prophylaxis)]TJ T* [(is)-489(recommended)-489(for)-489(patients)-489(with)-489(the)-489(conditions)-489(listed)-489(in)]TJ 0 -1.21 TD [(Table)-318(3)-318(who)-318(undergo)-318(any)-318(dental)-318(procedure)-318(that)-318(involves)-318(the)]TJ T* [(gingival)-330(tissues)-330(or)-330(periapical)-330(region)-330(of)-330(a)-330(tooth)-330(and)-330(for)-330(those)]TJ 0 -1.211 TD [(procedures)-229(that)-229(perforate)-229(the)-229(oral)-229(mucosa)-229(\(Table)-229(4\).)-229(Although)]TJ 0 -1.21 TD [(IE)-562(prophylaxis)-562(may)-562(be)-562(reasonable)-562(for)-562(these)-562(patients,)-562(its)]TJ T* [(effectiveness)-323(is)-323(unknown)]TJ /T1_1 1 Tf 10.577 0 Td (\()Tj /T1_3 1 Tf 0.333 0 Td [(Class)-323(IIb,)-323(LOE)-323(C)]TJ /T1_1 1 Tf 7.386 0 Td (\))Tj /T1_0 1 Tf 0.333 0 Td [(.)-323(This)-323(includes)]TJ -18.628 -1.21 Td [(procedures)-361(such)-361(as)-361(biopsies,)-361(suture)-361(removal,)-361(and)-361(placement)]TJ T* [(of)-419(orthodontic)-419(bands,)-419(but)-419(it)-419(does)-419(not)-419(include)-419(routine)-419(anes-)]TJ T* [(thetic)-515(injections)-515(through)-515(noninfected)-515(tissue,)-515(the)-515(taking)-515(of)]TJ T* [(dental)-287(radiographs,)-287(placement)-287(of)-287(removable)-287(prosthodontic)-287(or)]TJ T* [(orthodontic)-264(appliances,)-264(placement)-264(of)-264(orthodontic)-264(brackets,)-264(or)]TJ T* [(adjustment)-282(of)-282(orthodontic)-282(appliances.)-282(Finally,)-282(there)-282(are)-282(other)]TJ T* [(events)-336(that)-336(are)-336(not)-336(dental)-336(procedures)-336(and)-336(for)-336(which)-336(prophy-)]TJ 27.158 58.474 Td [(laxis)-465(is)-465(not)-465(recommended,)-465(such)-465(as)-465(shedding)-465(of)-465(deciduous)]TJ 0 -1.219 TD [(teeth)-333(and)-333(trauma)-333(to)-333(the)-333(lips)-333(and)-333(oral)-333(mucosa.)]TJ 1 -1.219 Td [(In)-351(this)-351(limited)-351(patient)-351(population,)-351(prophylactic)-351(antimicro-)]TJ -1 -1.219 Td [(bial)-330(therapy)-330(should)-330(be)-330(directed)-330(against)-330(viridans)-330(group)-330(strep-)]TJ T* [(tococci.)-336(During)-336(the)-336(past)-336(2)-336(decades,)-336(there)-336(has)-336(been)-336(a)-336(signifi-)]TJ T* [(cant)-392(increase)-392(in)-392(the)-392(percentage)-392(of)-392(strains)-392(of)-392(viridans)-392(group)]TJ T* [(streptococci)-273(resistant)-273(to)-273(antibiotics)-273(recommended)-273(in)-273(previous)]TJ T* [(AHA)-484(guidelines)-484(for)-484(the)-484(prevention)-484(of)-484(IE.)-484(Prabhu)-484(et)-484(al)]TJ 6.5 0 0 5.5 538.4128 527.358 Tm (135)Tj 9.5 0 0 9.5 314.1648 513.2472 Tm [(studied)-338(susceptibility)-338(patterns)-338(of)-338(viridans)-338(group)-338(streptococci)]TJ 0 -1.219 TD [(recovered)-406(from)-406(patients)-406(with)-406(IE)-406(diagnosed)-406(during)-406(a)-406(period)]TJ T* [(from)-343(1971)-343(to)-343(1986)-343(and)-343(compared)-343(these)-343(susceptibilities)-343(with)]TJ 0 -1.219 TD [(those)-441(of)-441(viridans)-441(group)-441(streptococci)-441(from)-441(patients)-441(with)-441(IE)]TJ 0 -1.219 TD [(diagnosed)-486(from)-486(1994)-486(to)-486(2002.)-486(In)-486(that)-486(study,)-486(none)-486(of)-486(the)]TJ T* [(strains)-250(of)-250(viridans)-250(group)-250(streptococci)-250(were)-250(penicillin)-250(resistant)]TJ T* [(in)-380(the)-380(early)-380(time)-380(period)-380(compared)-380(with)-380(13%)-380(of)-380(strains)-380(that)]TJ 0 -1.219 TD [(were)-464(intermediately)-464(or)-464(fully)-464(penicillin)-464(resistant)-464(during)-464(the)]TJ 0 -1.219 TD [(later)-226(time)-226(period.)-226(In)-226(that)-226(study,)-226(macrolide)-226(resistance)-226(increased)]TJ T* [(from)-227(11%)-227(to)-227(26%)-227(and)-227(clindamycin)-227(resistance)-227(from)-227(0%)-227(to)-227(4%.)]TJ 1 -1.219 Td [(Among)-302(352)-302(blood)-302(culture)-302(isolates)-302(of)-302(viridans)-302(group)-302(strep-)]TJ -1 -1.219 Td [(tococci,)-462(resistance)-462(rates)-462(were)-462(13%)-462(for)-462(penicillin,)-462(15%)-462(for)]TJ T* [(amoxicillin,)-286(17%)-285(for)-286(ceftriaxone,)-286(38%)-285(for)-286(erythromycin,)-286(and)]TJ 0 -1.218 TD [(96%)-300(for)-300(cephalexin.)]TJ 6.5 0 0 5.5 391.8737 365.2557 Tm (136)Tj 9.5 0 0 9.5 404.4707 362.7245 Tm [(The)-300(rank)-300(order)-300(of)-300(decreasing)-300(level)-300(of)]TJ -9.506 -1.218 Td [(activity)-512(of)-512(cephalosporins)-512(in)-512(that)-512(study)-512(was)-512(cefpodoxime)]TJ 0 -1.218 TD [(equal)-531(to)-531(ceftriaxone,)-531(greater)-531(than)-531(cefprozil,)-531(and)-531(equal)-531(to)]TJ T* [(cefuroxime,)-489(and)-489(cephalexin)-489(was)-489(the)-489(least)-489(active.)-489(In)-489(other)]TJ T* [(studies,)-270(resistance)-270(of)-270(viridans)-270(group)-270(streptococci)-270(to)-270(penicillin)]TJ T* [(ranged)-308(from)-308(17%)-308(to)-308(50%)]TJ 6.5 0 0 5.5 412.4117 307.4148 Tm (137\226142)Tj 9.5 0 0 9.5 438.0916 304.8835 Tm [(and)-308(resistance)-308(to)-308(ceftriaxone)]TJ -13.045 -1.218 Td [(ranged)-283(from)-283(22%)-283(to)-283(42%.)]TJ 6.5 0 0 5.5 413.8207 295.8466 Tm (131,140)Tj 9.5 0 0 9.5 437.634 293.3154 Tm [(Ceftriaxone)-283(was)-283(2)-283(to)-283(4)-283(times)]TJ -12.997 -1.218 Td [(more)-284(active)-284(in)-284(vitro)-284(than)-284(cefazolin.)]TJ 6.5 0 0 5.5 448.7636 284.2784 Tm (131,140)Tj 9.5 0 0 9.5 472.5911 281.7472 Tm [(Similarly)-284(high)-284(rates)]TJ -16.676 -1.218 Td [(of)-243(resistance)-243(were)-243(reported)-243(for)-243(macrolides,)-243(ranging)-243(from)-243(22%)]TJ T* [(to)-466(58%)]TJ 6.5 0 0 5.5 343.3941 261.1421 Tm (137,141,143,144)Tj 9.5 0 0 9.5 387.2708 258.6108 Tm [(;)-466(resistance)-466(to)-466(clindamycin)-466(ranged)-466(from)]TJ -7.695 -1.218 Td [(13%)-333(to)-333(27%.)]TJ 6.5 0 0 5.5 365.0793 249.5739 Tm (128,129,131,137,138,140)Tj 9.5 0 0 9.5 323.6648 235.4745 Tm [(Most)-410(of)-410(the)-410(strains)-410(of)-410(viridans)-410(group)-410(streptococci)-410(in)-410(the)]TJ -1 -1.218 Td [(above-cited)-234(studies)-234(were)-234(recovered)-234(from)-234(patients)-234(with)-234(serious)]TJ T* [(underlying)-296(illnesses,)-296(including)-296(malignancies)-296(and)-296(febrile)-296(neu-)]TJ T* [(tropenia.)-284(These)-284(patients)-284(are)-284(at)-284(increased)-284(risk)-284(of)-284(infection)-284(and)]TJ T* [(colonization)-388(by)-388(multiple-drug\226resistant)-388(microorganisms,)-388(in-)]TJ 0.0072 Tc T* [(cluding)-666(viridans)-666(group)-666(streptococci.)-666(Accordingly,)-666(these)]TJ 0 Tc T* [(strains)-288(may)-288(not)-288(be)-288(representative)-288(of)-288(susceptibility)-288(patterns)-288(of)]TJ 0 -1.218 TD [(viridans)-338(group)-338(streptococci)-338(recovered)-338(from)-338(presumably)-338(nor-)]TJ 0 -1.218 TD [(mal)-277(individuals)-277(who)-277(undergo)-277(a)-277(dental)-277(procedure.)-277(Diekema)-277(et)]TJ T* (al)Tj 6.5 0 0 5.5 321.0234 133.8921 Tm (137)Tj 9.5 0 0 9.5 334.2937 131.3608 Tm [(reported)-370(that)-370(32%)-370(of)-370(strains)-370(of)-370(viridans)-370(group)-370(strepto-)]TJ -2.119 -1.218 Td [(cocci)-361(were)-361(resistant)-361(to)-361(penicillin)-361(in)-361(patients)-361(without)-361(cancer.)]TJ 0 -1.218 TD [(King)-507(et)-507(al)]TJ 6.5 0 0 5.5 356.5118 110.7557 Tm (144)Tj 9.5 0 0 9.5 371.0775 108.2245 Tm [(reported)-507(erythromycin)-507(resistance)-507(in)-507(41%)-507(of)]TJ -5.991 -1.218 Td [(streptococci)-625(recovered)-625(from)-625(throat)-625(cultures)-625(in)-625(otherwise)]TJ T* [(healthy)-281(individuals)-281(who)-281(presented)-281(with)-281(mild)-281(respiratory)-281(tract)]TJ T* [(infections.)-364(In)-364(that)-364(study,)-364(after)-364(treatment)-364(with)-364(either)-364(azithro-)]TJ T* [(mycin)-222(or)-222(clindamycin,)-222(the)-222(percentage)-222(of)-222(resistant)-222(streptococci)]TJ T* [(increased)-452(to)-452(82%)-452(and)-452(71%,)-452(respectively.)-452(Accordingly,)-452(the)]TJ /T1_4 1 Tf 9 0 0 9 314.1648 720.3835 Tm [(TABLE)-333(4.)-1000(Dental)-333(Procedures)-333(for)-333(Which)-333(Endocarditis)]TJ 0 -1.167 TD [(Prophylaxis)-333(Is)-333(Recommended)-333(for)-333(Patients)-333(in)-333(Table)-333(3)]TJ ET 0 0 0 1 K 0.75 w 10 M 0 j 0 J []0 d 314.165 703.509 m 548.165 703.509 l 314.165 678.759 m 548.165 678.759 l S BT /T1_5 1 Tf 8 0 0 8 314.1648 693.1335 Tm [(All)-333(dental)-333(procedures)]TJ /T1_6 1 Tf 8.329 0 Td [(that)-333(involve)-333(manipulation)-333(of)-333(gingival)-333(tissue)-333(or)-333(the)]TJ -8.329 -1.25 Td [(periapical)-333(region)-333(of)-333(teeth)-333(or)-333(perforation)-333(of)-333(the)-333(oral)-333(mucosa*)]TJ 7 0 0 7 322.1648 669.3836 Tm [(*The)-459(following)-459(procedures)-459(and)-459(events)-459(do)-459(not)-459(need)-459(prophylaxis:)-459(routine)-459(anesthetic)]TJ -1.143 -1.429 Td [(injections)-299(through)-299(noninfected)-299(tissue,)-299(taking)-299(dental)-299(radiographs,)-299(placement)-299(of)-299(removable)]TJ 0 -1.429 TD [(prosthodontic)-279(or)-279(orthodontic)-279(appliances,)-279(adjustment)-279(of)-279(orthodontic)-279(appliances,)-279(placement)]TJ 0 -1.429 TD [(of)-244(orthodontic)-244(brackets,)-244(shedding)-244(of)-244(deciduous)-244(teeth,)-244(and)-244(bleeding)-244(from)-244(trauma)-244(to)-244(the)-244(lips)]TJ 0 -1.429 TD [(or)-333(oral)-333(mucosa.)]TJ /T1_1 1 Tf 10 0 0 10 288.7926 752.3835 Tm [(Wilson)-333(et)-333(al)-2000(Prevention)-333(of)-333(Infective)-333(Endocarditis)]TJ /T1_3 1 Tf 24.941 0 Td (11)Tj 0 g ET /GS1 gs BT /T1_7 1 Tf 9 0 0 9 294.7364 32 Tm ( by WARREN WALSH on April 19, 2007 )Tj 0 0 1 rg ET /GS1 gs BT /T1_7 1 Tf 9 0 0 9 223.2585 32 Tm (circ.ahajournals.org)Tj 0 g ET 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[(rates)-393(of)-393(viridans)-393(group)-393(streptococci)-393(provide)-393(additional)-393(sup-)]TJ T* [(port)-392(for)-392(the)-392(assertion)-392(that)-392(prophylactic)-392(therapy)-392(for)-392(a)-392(dental)]TJ T* [(procedure)-577(is)-577(of)-577(little,)-577(if)-577(any,)-577(value.)-577(It)-577(is)-577(impractical)-577(to)]TJ T* [(recommend)-349(prophylaxis)-349(with)-349(only)-349(those)-349(antibiotics,)-349(such)-349(as)]TJ T* [(vancomycin)-416(or)-416(a)-416(fluoroquinolone,)-416(that)-416(are)-416(highly)-416(active)-416(in)]TJ T* [(vitro)-465(against)-465(viridans)-465(group)-465(streptococci.)-465(There)-465(is)-465(no)-465(evi-)]TJ T* [(dence)-245(that)-245(such)-245(therapy)-245(is)-245(effective)-245(for)-245(prophylaxis)-245(of)-245(IE,)-245(and)]TJ T* [(their)-460(use)-460(might)-460(result)-460(in)-460(the)-460(development)-460(of)-460(resistance)-460(of)]TJ 0 -1.221 TD [(viridans)-588(group)-588(streptococci)-588(and)-588(other)-588(microorganisms)-588(to)]TJ 0 -1.221 TD [(these)-333(and)-333(other)-333(antibiotics.)]TJ 1 -1.221 Td [(In)-481(Table)-481(5,)-481(amoxicillin)-481(is)-481(the)-481(preferred)-481(choice)-481(for)-481(oral)]TJ -1 -1.221 Td [(therapy)-564(because)-564(it)-564(is)-564(well)-564(absorbed)-564(in)-564(the)-564(GI)-564(tract)-564(and)]TJ T* [(provides)-349(high)-349(and)-349(sustained)-349(serum)-349(concentrations.)-349(For)-349(indi-)]TJ T* [(viduals)-296(who)-296(are)-296(allergic)-296(to)-296(penicillins)-296(or)-296(amoxicillin,)-296(the)-296(use)]TJ T* [(of)-343(cephalexin)-343(or)-343(another)-343(first-generation)-343(oral)-343(cephalosporin,)]TJ 0.0075 Tc 0 -1.22 TD [(clindamycin,)-666(azithromycin,)-666(or)-666(clarithromycin)-666(is)-666(recom-)]TJ 0 Tc T* [(mended.)-539(Even)-539(though)-539(cephalexin)-539(was)-539(less)-539(active)-539(against)]TJ T* [(viridans)-458(group)-458(streptococci)-458(than)-458(other)-458(first-generation)-458(oral)]TJ T* [(cephalosporins)-302(in)-302(1)-302(study,)]TJ 6.5 0 0 5.5 156.8525 192.0057 Tm (136)Tj 9.5 0 0 9.5 169.4693 189.4745 Tm [(cephalexin)-302(is)-302(included)-302(in)-302(Table)]TJ -11.927 -1.22 Td [(5.)-475(No)-475(data)-475(show)-475(superiority)-475(of)-475(1)-475(oral)-475(cephalosporin)-475(over)]TJ 0 -1.22 TD [(another)-228(for)-228(prevention)-228(of)-228(IE,)-228(and)-228(generic)-228(cephalexin)-228(is)-228(widely)]TJ T* [(available)-555(and)-555(relatively)-555(inexpensive.)-555(Because)-555(of)-555(possible)]TJ T* [(cross-reactions,)-379(a)-379(cephalosporin)-379(should)-379(not)-379(be)-379(administered)]TJ 0 -1.22 TD [(to)-496(patients)-496(with)-496(a)-496(history)-496(of)-496(anaphylaxis,)-496(angioedema,)-496(or)]TJ T* [(urticaria)-236(after)-236(treatment)-236(with)-236(any)-236(form)-236(of)-236(penicillin,)-236(including)]TJ T* [(ampicillin)-298(or)-298(amoxicillin.)-298(Patients)-298(who)-298(are)-298(unable)-298(to)-298(tolerate)]TJ T* [(an)-267(oral)-267(antibiotic)-267(may)-267(be)-267(treated)-267(with)-267(ampicillin,)-267(ceftriaxone,)]TJ T* [(or)-433(cefazolin)-433(administered)-433(intramuscularly)-433(or)-433(intravenously.)]TJ T* [(For)-302(ampicillin-allergic)-302(patients)-302(who)-302(are)-302(unable)-302(to)-302(tolerate)-302(an)]TJ T* [(oral)-234(agent,)-234(therapy)-234(is)-234(recommended)-234(with)-234(parenteral)-234(cefazolin,)]TJ T* [(ceftriaxone,)-333(or)-333(clindamycin.)]TJ /T1_1 1 Tf 10.5 0 0 10.5 314.1648 467.3836 Tm [(Regimens)-333(for)-333(Respiratory)-333(Tract)-333(Procedures)]TJ /T1_0 1 Tf 9.5 0 0 9.5 314.1648 456.2358 Tm [(A)-496(variety)-496(of)-496(respiratory)-496(tract)-496(procedures)-496(reportedly)-496(cause)]TJ 0 -1.226 TD [(transient)-384(bacteremia)-384(with)-384(a)-384(wide)-384(array)-384(of)-384(microorganisms)]TJ 6.5 0 0 5.5 542.2845 447.1194 Tm (1)Tj 9.5 0 0 9.5 545.5347 444.5881 Tm (;)Tj -24.355 -1.226 Td [(however,)-349(no)-349(published)-349(data)-349(conclusively)-349(demonstrate)-349(a)-349(link)]TJ T* [(between)-238(these)-238(procedures)-238(and)-238(IE.)-238(Antibiotic)-238(prophylaxis)-238(with)]TJ 0 -1.226 TD [(a)-411(regimen)-411(listed)-411(in)-411(Table)-411(5)-411(may)-411(be)-411(considered)]TJ /T1_1 1 Tf 20.138 0 Td (\()Tj /T1_2 1 Tf 0.333 0 Td [(Class)-411(IIb,)]TJ -20.471 -1.226 Td [(LOE)-250(C)]TJ /T1_1 1 Tf 2.917 0 Td (\))Tj /T1_0 1 Tf 0.583 0 Td [(for)-250(patients)-250(with)-250(the)-250(conditions)-250(listed)-250(in)-250(Table)-250(3)-250(who)]TJ -3.499 -1.226 Td [(undergo)-427(an)-427(invasive)-427(procedure)-427(of)-427(the)-427(respiratory)-427(tract)-427(that)]TJ 0 -1.226 TD [(involves)-247(incision)-247(or)-247(biopsy)-247(of)-247(the)-247(respiratory)-247(mucosa,)-247(such)-247(as)]TJ T* [(tonsillectomy)-499(and)-499(adenoidectomy.)-499(We)-499(do)-499(not)-499(recommend)]TJ 0 -1.226 TD [(antibiotic)-273(prophylaxis)-273(for)-273(bronchoscopy)-273(unless)-273(the)-273(procedure)]TJ T* [(involves)-264(incision)-264(of)-264(the)-264(respiratory)-264(tract)-264(mucosa.)-264(For)-264(patients)]TJ T* [(listed)-392(in)-392(Table)-392(3)-392(who)-392(undergo)-392(an)-392(invasive)-392(respiratory)-392(tract)]TJ T* [(procedure)-347(to)-347(treat)-347(an)-347(established)-347(infection,)-347(such)-347(as)-347(drainage)]TJ T* [(of)-277(an)-277(abscess)-277(or)-277(empyema,)-277(we)-277(recommend)-277(that)-277(the)-277(antibiotic)]TJ T* [(regimen)-225(administered)-225(to)-225(these)-225(patients)-225(contain)-225(an)-225(agent)-225(active)]TJ 0 -1.226 TD [(against)-285(viridans)-285(group)-285(streptococci)-285(\(Table)-285(5\).)-285(If)-285(the)-285(infection)]TJ T* [(is)-607(known)-607(or)-607(suspected)-607(to)-607(be)-607(caused)-607(by)]TJ /T1_3 1 Tf 18.411 0 Td (Staphylococcus)Tj -18.411 -1.226 Td (aureus)Tj /T1_0 1 Tf 2.722 0 Td 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Tm [(Enterococci)-253(are)-253(part)-253(of)-253(the)-253(normal)-253(flora)-253(of)-253(the)-253(GI)-253(tract.)-253(These)]TJ T* [(microorganisms)-393(may)-393(cause)-393(intra-abdominal)-393(infection)-393(or)-393(in-)]TJ T* [(fection)-285(of)-285(the)-285(hepatobiliary)-285(system.)-285(Such)-285(infections)-285(are)-285(often)]TJ T* [(polymicrobial,)-410(with)-410(a)-410(mix)-410(of)-410(aerobic)-410(and)-410(anaerobic)-410(Gram-)]TJ 0.0006 Tc T* [(negative)-659(and)-659(Gram-positive)-659(microorganisms,)-659(but)-659(among)]TJ 0 Tc T* [(these)-287(varied)-287(bacteria,)-287(only)-287(enterococci)-287(are)-287(likely)-287(to)-287(cause)-287(IE.)]TJ T* [(Enterococci)-238(may)-238(cause)-238(urinary)-238(tract)-238(infections,)-238(particularly)-238(in)]TJ T* [(older)-297(males)-297(with)-297(prostatic)-297(hypertrophy)-297(and)-297(obstructive)-297(urop-)]TJ T* [(athy)-333(or)-333(prostatitis.)]TJ 1 -1.225 Td 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[(The)-364(high)-364(prevalence)-364(of)-364(resistant)-364(strains)-364(of)-364(enterococci)-364(adds)]TJ T* [(further)-372(doubt)-372(about)-372(the)-372(efficacy)-372(of)-372(prophylactic)-372(therapy)-372(for)]TJ T* [(GI)-333(or)-333(GU)-333(tract)-333(procedures.)]TJ 1 -1.218 Td [(Patients)-397(with)-397(infections)-397(of)-397(the)-397(GI)-397(or)-397(GU)-397(tract)-397(may)-397(have)]TJ -1 -1.218 Td [(intermittent)-509(or)-509(sustained)-509(enterococcal)-509(bacteremia.)-509(For)-509(pa-)]TJ 0 -1.218 TD [(tients)-502(with)-502(the)-502(conditions)-502(listed)-502(in)-502(Table)-502(3)-502(who)-502(have)-502(an)]TJ T* [(established)-281(GI)-281(or)-281(GU)-281(tract)-281(infection)-281(or)-281(for)-281(those)-281(who)-281(receive)]TJ T* [(antibiotic)-654(therapy)-654(to)-654(prevent)-654(wound)-654(infection)-654(or)-654(sepsis)]TJ T* [(associated)-572(with)-572(a)-572(GI)-572(or)-572(GU)-572(tract)-572(procedure,)-572(it)-572(may)-572(be)]TJ T* 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[(cal)-373(coverage)-373(for)-373(these)-373(patients.)-373(Vancomycin)-373(may)-373(be)-373(adminis-)]TJ T* [(tered)-464(to)-464(patients)-464(unable)-464(to)-464(tolerate)-464(ampicillin.)-464(If)-464(infection)-464(is)]TJ T* [(caused)-248(by)-248(a)-248(known)-248(or)-248(suspected)-248(strain)-248(of)-248(resistant)-248(enterococcus,)]TJ T* [(consultation)-258(with)-258(an)-258(infectious)-258(diseases)-258(expert)-258(is)-258(recommended.)]TJ /T1_1 1 Tf 0 Tc 10.5 0 0 10.5 56.1648 84.5881 Tm [(Recommendations)-333(for)-333(Procedures)-333(on)-333(Infected)]TJ 0 -1.102 TD [(Skin,)-333(Skin)-333(Structure,)-333(or)-333(Musculoskeletal)-333(Tissue)]TJ /T1_0 1 Tf 9.5 0 0 9.5 56.1648 61.9517 Tm [(These)-341(infections)-341(are)-341(often)-341(polymicrobial,)-341(but)-341(only)-341(staphylo-)]TJ 0 -1.218 TD [(cocci)-247(and)]TJ /T1_3 1 Tf 9.5 0 1.4773 9.5 94.6192 50.3835 Tm (\001)Tj /T1_0 1 Tf 9.5 0 0 9.5 100.4234 50.3835 Tm [(-hemolytic)-247(streptococci)-247(are)-247(likely)-247(to)-247(cause)-247(IE.)-247(For)]TJ 22.499 38.737 Td [(patients)-319(with)-319(the)-319(conditions)-319(listed)-319(in)-319(Table)-319(3)-319(who)-319(undergo)-319(a)]TJ 0 -1.237 TD [(surgical)-289(procedure)-289(that)-289(involves)-289(infected)-289(skin,)-289(skin)-289(structure,)]TJ T* [(or)-271(musculoskeletal)-271(tissue,)-271(it)-271(is)-271(reasonable)-271(that)-271(the)-271(therapeutic)]TJ T* [(regimen)-385(administered)-385(for)-385(treatment)-385(of)-385(the)-385(infection)-385(contain)]TJ T* [(an)-305(agent)-305(active)-305(against)-305(staphylococci)-305(and)]TJ /T1_3 1 Tf 9.5 0 1.4773 9.5 476.6638 371.3836 Tm (\001)Tj /T1_0 1 Tf 9.5 0 0 9.5 482.468 371.3836 Tm [(-hemolytic)-305(strep-)]TJ -17.716 -1.237 Td [(tococci,)-340(such)-340(as)-340(an)-340(antistaphylococcal)-340(penicillin)-340(or)-340(a)-340(cepha-)]TJ 0 -1.237 TD [(losporin)-312(\(Table)-312(5)-312(for)-312(dosage;)]TJ /T1_2 1 Tf 12.167 0 Td 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T* [(dations)-588(by)-588(the)-588(American)-588(Heart)-588(Association.)]TJ /T1_2 1 Tf 21.094 0 Td (JAMA)Tj /T1_1 1 Tf 2.641 0 Td [(.)-588(1990;264:)]TJ 0 Tc -23.735 -1.209 Td [(2919)-120(\2262922.)]TJ 0.0072 Tc -1.743 -1.209 Td [(14.)-507(Selton-Suty)-560(C,)-560(Duval)-560(X,)-560(Brochet)-560(E,)-560(Doco-Lecompte)-560(T,)-560(Hoen)-560(B,)]TJ 0 Tc 1.743 -1.209 Td [(Delahaye)-221(E,)-221(Leport)-221(C,)-221(Danchin)-221(N.)-221(New)-221(French)-221(recommendations)-221(for)-221(the)]TJ T* [(prophylaxis)-505(of)-505(infectious)-505(endocarditis)-505([in)-505(French].)]TJ /T1_2 1 Tf 21.888 0 Td [(Arch)-505(Mal)-505(Coeur)]TJ -21.888 -1.209 Td (Vaiss)Tj /T1_1 1 Tf 2.167 0 Td [(.)-333(2004;97:626)-120(\226)-120(631.)]TJ -3.917 -1.209 Td [(15.)-500(Gould)-395(FK,)-395(Elliott)-395(TS,)-395(Foweraker)-395(J,)-395(Fulford)-395(M,)-395(Perry)-395(JD,)-395(Robert)-395(GJ,)]TJ 1.75 -1.209 Td 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[(This)-335(table)-335(represents)-335(the)-335(relationships)-335(of)-335(reviewers)-335(that)-335(may)-335(be)-335(perceived)-335(as)-335(actual)-335(or)-335(reasonably)-335(perceived)-335(conflicts)-335(of)-335(interest)-335(as)-335(reported)-335(on)-335(the)]TJ 56.669 0 Td (Disclosure)Tj -57.669 -1.25 Td [(Questionnaire,)-305(which)-305(all)-305(reviewers)-305(are)-305(required)-305(to)-305(complete)-305(and)-305(submit.)-305(A)-305(relationship)-305(is)-305(considered)-305(to)-305(be)-305(\223Significant\224)-305(if)-305(\(1\))-305(the)-305(person)-305(receives)-305($)]TJ 55.62 0 Td [(10)-240(000)-305(or)-305(more)]TJ -55.62 -1.25 Td [(during)-332(any)-332(12-month)-332(period,)-332(or)-332(5%)-332(or)-332(more)-332(of)-332(the)-332(person\222s)-332(gross)-332(income;)-332(or)-332(\(2\))-332(the)-332(person)-332(owns)-332(5%)-332(or)-332(more)-332(of)-332(the)-332(voting)-332(stock)-332(or)-332(share)-332(of)-332(the)-332(entity)-332(or)-332(owns)]TJ 0 -1.25 TD 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720.8835 Tm [(23.)-500(Okell)-445(CC,)-445(Elliott)-445(SD.)-445(Bacteraemia)-445(and)-445(oral)-445(sepsis:)-445(with)-445(special)-445(ref-)]TJ 0.0106 Tc 1.75 -1.209 Td [(erence)-563(to)-563(the)-563(aetiology)-563(of)-563(subacute)-563(endocarditis.)]TJ /T1_1 1 Tf 22.2 0 Td (Lancet)Tj /T1_0 1 Tf 2.786 0 Td [(.)-563(1935;2:)]TJ 0 Tc -24.985 -1.209 Td [(869)-120(\226)-120(872.)]TJ -1.75 -1.209 Td [(24.)-500(Lockhart)-244(PB,)-244(Durack)-244(DT.)-244(Oral)-244(microflora)-244(as)-244(a)-244(cause)-244(of)-244(endocarditis)-244(and)]TJ 0.0125 Tc 1.75 -1.209 Td [(other)-565(distant)-565(site)-565(infections.)]TJ /T1_1 1 Tf 12.903 0 Td [(Infect)-565(Dis)-565(Clin)-565(North)-565(Am)]TJ /T1_0 1 Tf 11.567 0 Td [(.)-565(1999;13:)]TJ 0 Tc -24.47 -1.209 Td [(833\226)-120(850,)-333(vi.)]TJ -1.75 -1.209 Td [(25.)-500(Roberts)-293(GJ,)-293(Holzel)-293(HS,)-293(Sury)-293(MR,)-293(Simmons)-293(NA,)-293(Gardner)-293(P,)-293(Longhurst)]TJ 1.75 -1.209 Td [(P.)-333(Dental)-333(bacteremia)-333(in)-333(children.)]TJ /T1_1 1 Tf 13.829 0 Td [(Pediatr)-333(Cardiol)]TJ /T1_0 1 Tf 6.445 0 Td [(.)-333(1997;18:24)-120(\22627.)]TJ -22.024 -1.209 Td [(26.)-500(Pallasch)-476(TJ,)-476(Slots)-476(J.)-476(Antibiotic)-476(prophylaxis)-476(and)-476(the)-476(medically)-476(com-)]TJ 1.75 -1.209 Td [(promised)-333(patient.)]TJ /T1_1 1 Tf 7.36 0 Td [(Periodontol)-333(2000)]TJ /T1_0 1 Tf 7.111 0 Td [(.)-333(1996;10:107\226138.)]TJ -16.221 -1.209 Td [(27.)-500(Lockhart)-372(PB.)-372(The)-372(risk)-372(for)-372(endocarditis)-372(in)-372(dental)-372(practice.)]TJ /T1_1 1 Tf 25.923 0 Td (Periodontol)Tj -24.173 -1.209 Td (2000)Tj /T1_0 1 Tf 2 0 Td [(.)-333(2000;23:127\226135.)]TJ -3.75 -1.209 Td [(28.)-500(Cobe)-436(HM.)-436(Transitory)-436(bacteremia.)]TJ /T1_1 1 Tf 16.27 0 Td [(Oral)-436(Surg)-436(Oral)-436(Med)-436(Oral)-436(Pathol)]TJ /T1_0 1 Tf 14.182 0 Td (.)Tj -28.702 -1.209 Td [(1954;7:609)-120(\226)-120(615.)]TJ -1.75 -1.209 Td [(29.)-500(Sconyers)-350(JR,)-350(Crawford)-350(JJ,)-350(Moriarty)-350(JD.)-350(Relationship)-350(of)-350(bacteremia)-350(to)]TJ 1.75 -1.209 Td [(toothbrushing)-285(in)-285(patients)-285(with)-285(periodontitis.)]TJ /T1_1 1 Tf 17.953 0 Td [(J)-285(Am)-285(Dent)-285(Assoc)]TJ /T1_0 1 Tf 6.909 0 Td [(.)-285(1973;87:)]TJ -24.862 -1.209 Td [(616)-120(\226)-120(622.)]TJ -1.75 -1.209 Td [(30.)-500(Forner)-401(L,)-401(Larsen)-401(T,)-401(Kilian)-401(M,)-401(Holmstrup)-401(P.)-401(Incidence)-401(of)-401(bacteremia)]TJ 1.75 -1.209 Td [(after)-233(chewing,)-233(tooth)-233(brushing)-233(and)-233(scaling)-233(in)-233(individuals)-233(with)-233(periodontal)]TJ 0 -1.209 TD (inflammation.)Tj /T1_1 1 Tf 5.972 0 Td [(J)-333(Clin)-333(Periodontol)]TJ /T1_0 1 Tf 7.611 0 Td [(.)-333(2006;33:401\226)-120(407.)]TJ -15.333 -1.209 Td [(31.)-500(Rise)-397(E,)-397(Smith)-397(JF,)-397(Bell)-397(J.)-397(Reduction)-397(of)-397(bacteremia)-397(after)-397(oral)-397(manipu-)]TJ 1.75 -1.209 Td (lations.)Tj /T1_1 1 Tf 3.25 0 Td [(Arch)-333(Otolaryngol)]TJ /T1_0 1 Tf 7.166 0 Td [(.)-333(1969;90:198)-120(\226201.)]TJ -12.166 -1.209 Td [(32.)-500(Schlein)-343(RA,)-343(Kudlick)-343(EM,)-343(Reindorf)-343(CA,)-343(Gregory)-343(J,)-343(Royal)-343(GC.)-343(Tooth-)]TJ 1.75 -1.209 Td [(brushing)-446(and)-446(transient)-446(bacteremia)-446(in)-446(patients)-446(undergoing)-446(orthodontic)]TJ T* (treatment.)Tj /T1_1 1 Tf 4.36 0 Td [(Am)-333(J)-333(Orthod)-333(Dentofacial)-333(Orthop)]TJ /T1_0 1 Tf 13.609 0 Td [(.)-333(1991;99:466)-120(\226)-120(472.)]TJ -19.719 -1.209 Td [(33.)-500(Faden)-369(HS.)-369(Letter:)-369(dental)-369(procedures)-369(and)-369(bacteremia.)]TJ /T1_1 1 Tf 23.883 0 Td [(Ann)-369(Intern)-369(Med)]TJ /T1_0 1 Tf 6.57 0 Td (.)Tj -28.702 -1.209 Td (1974;81:274.)Tj -1.75 -1.208 Td [(34.)-500(Round)-331(H,)-331(Kirkpatrick)-331(HJR,)-331(Hails)-331(CG.)-331(Further)-331(investigations)-331(on)-331(bacte-)]TJ 1.75 -1.208 Td [(riological)-220(infections)-220(of)-220(the)-220(mouth.)]TJ /T1_1 1 Tf 13.738 0 Td [(Proc)-220(R)-220(Soc)-220(Med)]TJ /T1_0 1 Tf 6.436 0 Td [(.)-220(1936;29:1552\2261556.)]TJ -21.925 -1.208 Td [(35.)-500(Felix)-285(JE,)-285(Rosen)-285(S,)-285(App)-285(GR.)-285(Detection)-285(of)-285(bacteremia)-285(after)-285(the)-285(use)-285(of)-285(an)]TJ 1.75 -1.208 Td [(oral)-248(irrigation)-248(device)-248(in)-248(subjects)-248(with)-248(periodontitis.)]TJ /T1_1 1 Tf 20.705 0 Td [(J)-248(Periodontol)]TJ /T1_0 1 Tf 5.47 0 Td [(.)-248(1971;)]TJ -26.175 -1.208 Td (42:785\226787.)Tj -1.75 -1.208 Td [(36.)-500(O\222Leary)-488(TJ,)-488(Shafer)-488(WG,)-488(Swenson)-488(HM,)-488(Nesler)-488(DC,)-488(Van)-488(Dorn)-488(PR.)]TJ 1.75 -1.208 Td [(Possible)-233(penetration)-233(of)-233(crevicular)-233(tissue)-233(from)-233(oral)-233(hygiene)-233(procedures,)-233(I:)]TJ 0 -1.208 TD [(use)-333(of)-333(oral)-333(irrigating)-333(devices.)]TJ /T1_1 1 Tf 12.357 0 Td [(J)-333(Periodontol)]TJ /T1_0 1 Tf 5.555 0 Td [(.)-333(1970;41:158)-120(\226162.)]TJ 0.0261 Tc -19.636 -1.208 Td [(37.)-526(Socransky)-579(SS,)-579(Haffajee)-579(AD,)-579(Smith)-579(GL,)-579(Dzink)-579(JL.)-579(Difficulties)]TJ 0 Tc 1.724 -1.208 Td [(encountered)-396(in)-396(the)-396(search)-396(for)-396(the)-396(etiologic)-396(agents)-396(of)-396(destructive)-396(peri-)]TJ T* [(odontal)-333(diseases.)]TJ /T1_1 1 Tf 7.193 0 Td [(J)-333(Clin)-333(Periodontol)]TJ /T1_0 1 Tf 7.611 0 Td [(.)-333(1987;14:588)-120(\226593.)]TJ -16.554 -1.208 Td [(38.)-500(Tanner)-445(A,)-445(Maiden)-445(MF,)-445(Paster)-445(BJ,)-445(Dewhirst)-445(FE.)-445(The)-445(impact)-445(of)-445(16S)]TJ 1.75 -1.208 Td [(ribosomal)-498(RNA-based)-498(phylogeny)-498(on)-498(the)-498(taxonomy)-498(of)-498(oral)-498(bacteria.)]TJ /T1_1 1 Tf T* [(Periodontol)-333(2000)]TJ /T1_0 1 Tf 7.111 0 Td [(.)-333(1994;5:26)-120(\22651.)]TJ -8.861 -1.208 Td [(39.)-500(Paster)-354(BJ,)-354(Boches)-354(SK,)-354(Galvin)-354(JL,)-354(Ericson)-354(RE,)-354(Lau)-354(CN,)-354(Levanos)-354(VA,)]TJ 1.75 -1.208 Td [(Sahasrabudhe)-258(A,)-258(Dewhirst)-258(FE.)-258(Bacterial)-258(diversity)-258(in)-258(human)-258(subgingival)]TJ T* (plaque.)Tj /T1_1 1 Tf 3.249 0 Td [(J)-333(Bacteriol)]TJ /T1_0 1 Tf 4.499 0 Td [(.)-333(2001;183:3770)-120(\2263783.)]TJ -9.498 -1.208 Td [(40.)-500(Aas)-478(JA,)-478(Paster)-478(BJ,)-478(Stokes)-478(LN,)-478(Olsen)-478(I,)-478(Dewhirst)-478(FE.)-478(Defining)-478(the)]TJ 1.75 -1.208 Td [(normal)-451(bacterial)-451(flora)-451(of)-451(the)-451(oral)-451(cavity.)]TJ /T1_1 1 Tf 17.623 0 Td [(J)-451(Clin)-451(Microbiol)]TJ /T1_0 1 Tf 7.068 0 Td [(.)-451(2005;43:)]TJ -24.692 -1.208 Td (5721\2265732.)Tj -1.75 -1.208 Td [(41.)-500(Pallasch)-445(TJ.)-445(Antibiotic)-445(prophylaxis:)-445(problems)-445(in)-445(paradise.)]TJ /T1_1 1 Tf 26.589 0 Td [(Dent)-445(Clin)]TJ -24.839 -1.208 Td [(North)-333(Am)]TJ /T1_0 1 Tf 4 0 Td [(.)-333(2003;47:665\226)-120(679.)]TJ -5.75 -1.208 Td [(42.)-500(Hillman)-264(JD,)-264(Socransky)-264(SS,)-264(Shivers)-264(M.)-264(The)-264(relationships)-264(between)-264(strep-)]TJ 1.75 -1.208 Td [(tococcal)-311(species)-311(and)-311(periodontopathic)-311(bacteria)-311(in)-311(human)-311(dental)-311(plaque.)]TJ /T1_1 1 Tf T* [(Arch)-333(Oral)-333(Biol)]TJ /T1_0 1 Tf 6.166 0 Td [(.)-333(1985;30:791\226795.)]TJ -7.916 -1.208 Td [(43.)-500(Roberts)-415(GJ,)-415(Jaffray)-415(EC,)-415(Spratt)-415(DA,)-415(Petrie)-415(A,)-415(Greville)-415(C,)-415(Wilson)-415(M,)]TJ 1.75 -1.208 Td [(Lucas)-230(VS.)-230(Duration,)-230(prevalence)-230(and)-230(intensity)-230(of)-230(bacteraemia)-230(after)-230(dental)]TJ T* [(extractions)-333(in)-333(children.)]TJ /T1_1 1 Tf 9.692 0 Td (Heart)Tj /T1_0 1 Tf 2.333 0 Td [(.)-333(2006;92:1274)-120(\2261277.)]TJ -13.775 -1.208 Td [(44.)-500(Lucas)-279(VS,)-279(Lytra)-279(V,)-279(Hassan)-279(T,)-279(Tatham)-279(H,)-279(Wilson)-279(M,)-279(Roberts)-279(GJ.)-279(Com-)]TJ 0.0072 Tc 1.75 -1.208 Td [(parison)-560(of)-560(lysis)-560(filtration)-560(and)-560(an)-560(automated)-560(blood)-560(culture)-560(system)]TJ 0 Tc T* [(\(BACTEC\))-501(for)-501(detection,)-501(quantification,)-501(and)-501(identification)-501(of)-501(odon-)]TJ T* [(togenic)-333(bacteremia)-333(in)-333(children.)]TJ /T1_1 1 Tf 12.968 0 Td [(J)-333(Clin)-333(Microbiol)]TJ /T1_0 1 Tf 6.833 0 Td [(.)-333(2002;40:3416)-120(\2263420.)]TJ -21.551 -1.208 Td [(45.)-500(Lockhart)-453(PB,)-453(Schmidtke)-453(MA.)-453(Antibiotic)-453(considerations)-453(in)-453(medically)]TJ 1.75 -1.208 Td [(compromised)-333(patients.)]TJ /T1_1 1 Tf 9.471 0 Td [(Dent)-333(Clin)-333(North)-333(Am)]TJ /T1_0 1 Tf 8.333 0 Td [(.)-333(1994;38:381\226)-120(402.)]TJ -19.554 -1.208 Td [(46.)-500(Overholser)-426(CD,)-426(Moreillon)-426(P,)-426(Glauser)-426(MP.)-426(Experimental)-426(endocarditis)]TJ 1.75 -1.208 Td [(following)-418(dental)-418(extractions)-418(in)-418(rats)-418(with)-418(periodontitis)-418([published)-418(cor-)]TJ T* [(rection)-345(appears)-345(in)]TJ /T1_1 1 Tf 7.645 0 Td [(J)-345(Oral)-345(Maxillofac)-345(Surg)]TJ /T1_0 1 Tf 9.591 0 Td [(.)-345(1989;47:215].)]TJ /T1_1 1 Tf 6.58 0 Td [(J)-345(Oral)-345(Max-)]TJ -23.817 -1.208 Td [(illofac)-333(Surg)]TJ /T1_0 1 Tf 4.778 0 Td [(.)-333(1988;46:857\226)-120(861.)]TJ -6.528 -1.208 Td [(47.)-500(Baltch)-253(AL,)-253(Schaffer)-253(C,)-253(Hammer)-253(MC,)-253(Sutphen)-253(NT,)-253(Smith)-253(RP,)-253(Conroy)-253(J,)]TJ 1.75 -1.208 Td [(Shayegani)-251(M.)-251(Bacteremia)-251(following)-251(dental)-251(cleaning)-251(in)-251(patients)-251(with)-251(and)]TJ T* [(without)-333(penicillin)-333(prophylaxis.)]TJ /T1_1 1 Tf 12.805 0 Td [(Am)-333(Heart)-333(J)]TJ /T1_0 1 Tf 4.776 0 Td [(.)-333(1982;104:1335\2261339.)]TJ 0.0148 Tc -19.316 -1.208 Td [(48.)-515(Baltch)-567(AL,)-567(Pressman)-567(HL,)-567(Schaffer)-567(C,)-567(Smith)-567(RP,)-567(Hammer)-567(MC,)]TJ 0 Tc 1.735 -1.208 Td [(Shayegani)-515(M,)-515(Michelsen)-515(P.)-515(Bacteremia)-515(in)-515(patients)-515(undergoing)-515(oral)]TJ T* [(procedures:)-256(study)-256(following)-256(parenteral)-256(antimicrobial)-256(prophylaxis)-256(as)-256(rec-)]TJ T* [(ommended)-276(by)-276(the)-276(American)-276(Heart)-276(Association,)-276(1977.)]TJ /T1_1 1 Tf 21.985 0 Td [(Arch)-276(Intern)-276(Med)]TJ /T1_0 1 Tf 6.717 0 Td (.)Tj -28.702 -1.208 Td [(1988;148:1084)-120(\2261088.)]TJ -1.75 -1.208 Td [(49.)-500(Coffin)-501(F,)-501(Thompson)-501(RE.)-501(Factors)-501(influencing)-501(bacteraemia)-501(following)]TJ 1.75 -1.208 Td [(dental)-333(extraction.)]TJ /T1_1 1 Tf 7.359 0 Td (Lancet)Tj /T1_0 1 Tf 2.722 0 Td [(.)-333(1956;271:654)-120(\226)-120(656.)]TJ 22.569 89.4 Td [(50.)-500(Heimdahl)-228(A,)-228(Hall)-228(G,)-228(Hedberg)-228(M,)-228(Sandberg)-228(H,)-228(Soder)-228(PO,)-228(Tuner)-228(K,)-228(Nord)]TJ 1.75 -1.209 Td [(CE.)-449(Detection)-449(and)-449(quantitation)-449(by)-449(lysis-filtration)-449(of)-449(bacteremia)-449(after)]TJ 0.0375 Tc 0 -1.209 TD [(different)-590(oral)-590(surgical)-590(procedures.)]TJ /T1_1 1 Tf 16.362 0 Td [(J)-590(Clin)-590(Microbiol)]TJ /T1_0 1 Tf 7.872 0 Td [(.)-590(1990;28:)]TJ 0 Tc -24.234 -1.209 Td (2205\2262209.)Tj -1.75 -1.209 Td [(51.)-500(Lucartorto)-400(FM,)-400(Franker)-400(CK,)-400(Maza)-400(J.)-400(Postscaling)-400(bacteremia)-400(in)-400(HIV-)]TJ 1.75 -1.209 Td [(associated)-229(gingivitis)-229(and)-229(periodontitis.)]TJ /T1_1 1 Tf 15.556 0 Td [(Oral)-229(Surg)-229(Oral)-229(Med)-229(Oral)-229(Pathol)]TJ /T1_0 1 Tf 13.146 0 Td (.)Tj -28.701 -1.209 Td [(1992;73:550)-120(\226554.)]TJ -1.75 -1.209 Td [(52.)-500(Lockhart)-406(PB.)-406(An)-406(analysis)-406(of)-406(bacteremias)-406(during)-406(dental)-406(extractions:)-406(a)]TJ 1.75 -1.209 Td [(double-blind,)-492(placebo-controlled)-492(study)-492(of)-492(chlorhexidine.)]TJ /T1_1 1 Tf 24.07 0 Td [(Arch)-492(Intern)]TJ -24.07 -1.209 Td (Med)Tj /T1_0 1 Tf 1.777 0 Td [(.)-333(1996;156:513\226520.)]TJ -3.527 -1.209 Td [(53.)-500(Lockhart)-309(PB,)-309(Brennan)-309(MT,)-309(Kent)-309(ML,)-309(Norton)-309(HJ,)-309(Weinrib)-309(DA.)-309(Impact)]TJ 1.75 -1.209 Td [(of)-464(amoxicillin)-464(prophylaxis)-464(on)-464(the)-464(incidence,)-464(nature,)-464(and)-464(duration)-464(of)]TJ 0 -1.209 TD [(bacteremia)-436(in)-436(children)-436(after)-436(intubation)-436(and)-436(dental)-436(procedures.)]TJ /T1_1 1 Tf 26.34 0 Td (Circu-)Tj -26.34 -1.209 Td (lation)Tj /T1_0 1 Tf 2.334 0 Td [(.)-333(2004;109:2878)-120(\2262884.)]TJ 0.0208 Tc -4.063 -1.209 Td [(54.)-521(Lazansky)-573(JP,)-573(Robinson)-573(L,)-573(Rodofsky)-573(L.)-573(Factors)-573(influencing)-573(the)]TJ 0.0011 Tc 1.729 -1.209 Td [(incidence)-554(of)-554(bacteremias)-554(following)-554(surgical)-554(procedures)-554(in)-554(the)-554(oral)]TJ 0 Tc T* (cavity.)Tj /T1_1 1 Tf 3.027 0 Td [(J)-333(Dent)-333(Res)]TJ /T1_0 1 Tf 4.498 0 Td [(.)-333(1949;28:533\226543.)]TJ -9.275 -1.209 Td [(55.)-500(Bender)-335(IB,)-335(Montgomery)-335(S.)-335(Nonsurgical)-335(endodontic)-335(procedures)-335(for)-335(the)]TJ 1.75 -1.209 Td [(patient)-309(at)-309(risk)-309(for)-309(infective)-309(endocarditis)-309(and)-309(other)-309(systemic)-309(disorders.)]TJ /T1_1 1 Tf 28.507 0 Td (J)Tj -28.507 -1.209 Td (Endod)Tj /T1_0 1 Tf 2.611 0 Td [(.)-333(1986;12:400)-120(\226)-120(407.)]TJ -4.361 -1.209 Td [(56.)-500(Conner)-341(HD,)-341(Haberman)-341(S,)-341(Collings)-341(CK,)-341(Winford)-341(TE.)-341(Bacteremias)-341(fol-)]TJ 1.75 -1.209 Td [(lowing)-282(periodontal)-282(scaling)-282(in)-282(patients)-282(with)-282(healthy)-282(appearing)-282(gingiva.)]TJ /T1_1 1 Tf 28.506 0 Td (J)Tj -28.506 -1.209 Td (Periodontol)Tj /T1_0 1 Tf 4.778 0 Td [(.)-333(1967;38:466)-120(\226)-120(472.)]TJ 0.0356 Tc -6.492 -1.209 Td [(57.)-536(McEntegart)-588(MG,)-588(Porterfield)-588(JS.)-588(Bacteraemia)-588(following)-588(dental)]TJ 0 Tc 1.714 -1.209 Td (extractions.)Tj /T1_1 1 Tf 4.971 0 Td (Lancet)Tj /T1_0 1 Tf 2.722 0 Td [(.)-333(1949;2:596)-120(\226598.)]TJ -9.443 -1.209 Td [(58.)-500(Robinson)-304(L,)-304(Kraus)-304(FW,)-304(Lazansky)-304(JP,)-304(Wheeler)-304(RE,)-304(Gordon)-304(S,)-304(Johnson)]TJ 1.75 -1.209 Td [(V.)-385(Bacteremias)-385(of)-385(dental)-385(origin,)-385(II:)-385(a)-385(study)-385(of)-385(the)-385(factors)-385(influencing)]TJ 0 -1.208 TD [(occurrence)-433(and)-433(detection.)]TJ /T1_1 1 Tf 11.046 0 Td [(Oral)-433(Surg)-433(Oral)-433(Med)-433(Oral)-433(Pathol)]TJ /T1_0 1 Tf 14.167 0 Td [(.)-433(1950;3:)]TJ -25.213 -1.208 Td (923\226936.)Tj -1.75 -1.208 Td [(59.)-500(Eldirini)-366(AH.)-366(Effectiveness)-366(of)-366(epinephrine)-366(in)-366(local)-366(anesthetic)-366(solutions)]TJ 1.75 -1.208 Td [(on)-316(the)-316(bacteremia)-316(following)-316(dental)-316(extraction.)]TJ /T1_1 1 Tf 19.086 0 Td [(J)-316(Oral)-316(Ther)-316(Pharmacol)]TJ /T1_0 1 Tf 9.614 0 Td (.)Tj -28.7 -1.208 Td (1968;4:317\226326.)Tj -1.75 -1.208 Td [(60.)-500(Elliott)-258(RH,)-258(Dunbar)-258(JM.)-258(Streptococcal)-258(bacteraemia)-258(in)-258(children)-258(following)]TJ 1.75 -1.208 Td [(dental)-333(extractions.)]TJ /T1_1 1 Tf 7.748 0 Td [(Arch)-333(Dis)-333(Child)]TJ /T1_0 1 Tf 6.222 0 Td [(.)-333(1968;43:451\226)-120(454.)]TJ -15.72 -1.208 Td [(61.)-500(Vargas)-259(B,)-259(Collings)-259(CK,)-259(Polter)-259(L,)-259(Haberman)-259(S.)-259(Effects)-259(of)-259(certain)-259(factors)]TJ 1.75 -1.208 Td [(on)-355(bacteremias)-355(resulting)-355(from)-355(gingival)-355(resection.)]TJ /T1_1 1 Tf 20.49 0 Td [(J)-355(Periodontal)]TJ /T1_0 1 Tf 5.577 0 Td [(.)-355(1959;)]TJ -26.067 -1.208 Td [(30:196)-120(\226207.)]TJ -1.75 -1.208 Td [(62.)-500(Roberts)-412(GJ.)-412(Dentists)-412(are)-412(innocent!)-412(\223Everyday\224)-412(bacteremia)-412(is)-412(the)-412(real)]TJ 1.75 -1.208 Td [(culprit:)-429(a)-429(review)-429(and)-429(assessment)-429(of)-429(the)-429(evidence)-429(that)-429(dental)-429(surgical)]TJ 0 -1.208 TD [(procedures)-406(are)-406(a)-406(principal)-406(cause)-406(of)-406(bacterial)-406(endocarditis)-406(in)-406(children.)]TJ /T1_1 1 Tf T* [(Pediatr)-333(Cardiol)]TJ /T1_0 1 Tf 6.445 0 Td [(.)-333(1999;20:317\226325.)]TJ -8.195 -1.208 Td [(63.)-500(Hockett)-297(RN,)-297(Loesche)-297(WJ,)-297(Sodeman)-297(TM.)-297(Bacteraemia)-297(in)-297(asymptomatic)]TJ 1.75 -1.208 Td [(human)-333(subjects.)]TJ /T1_1 1 Tf 6.86 0 Td [(Arch)-333(Oral)-333(Biol)]TJ /T1_0 1 Tf 6.166 0 Td [(.)-333(1977;22:91\22698.)]TJ -14.776 -1.208 Td [(64.)-500(Thayer)-349(W.)-349(Studies)-349(on)-349(bacterial)-349(\(infective\))-349(endocarditis.)]TJ /T1_1 1 Tf 24.909 0 Td [(Hopkins)-349(Hosp)]TJ -23.159 -1.208 Td (Rep)Tj /T1_0 1 Tf 1.555 0 Td [(.)-333(1926;22:1\226185.)]TJ -3.305 -1.208 Td [(65.)-500(Okabe)-308(K,)-308(Nakagawa)-308(K,)-308(Yamamoto)-308(E.)-308(Factors)-308(affecting)-308(the)-308(occurrence)]TJ 1.75 -1.208 Td [(of)-418(bacteremia)-418(associated)-418(with)-418(tooth)-418(extraction.)]TJ /T1_1 1 Tf 19.92 0 Td [(Int)-418(J)-418(Oral)-418(Maxillofac)]TJ -19.92 -1.208 Td (Surg)Tj /T1_0 1 Tf 1.889 0 Td [(.)-333(1995;24:239)-120(\226242.)]TJ -3.639 -1.208 Td [(66.)-500(Hall)-415(G,)-415(Hedstrom)-415(SA,)-415(Heimdahl)-415(A,)-415(Nord)-415(CE.)-415(Prophylactic)-415(adminis-)]TJ 1.75 -1.208 Td [(tration)-362(of)-362(penicillins)-362(for)-362(endocarditis)-362(does)-362(not)-362(reduce)-362(the)-362(incidence)-362(of)]TJ T* [(postextraction)-333(bacteremia.)]TJ /T1_1 1 Tf 10.969 0 Td [(Clin)-333(Infect)-333(Dis)]TJ /T1_0 1 Tf 6.055 0 Td [(.)-333(1993;17:188)-120(\226194.)]TJ -18.774 -1.208 Td [(67.)-500(Lineberger)-403(LT,)-403(De)-403(Marco)-403(TJ.)-403(Evaluation)-403(of)-403(transient)-403(bacteremia)-403(fol-)]TJ 1.75 -1.208 Td [(lowing)-228(routine)-228(periodontal)-228(procedures.)]TJ /T1_1 1 Tf 15.717 0 Td [(J)-228(Periodontol)]TJ /T1_0 1 Tf 5.45 0 Td [(.)-228(1973;44:757\226762.)]TJ -22.917 -1.208 Td [(68.)-500(Witzenberger)-226(T,)-226(O\222Leary)-226(TJ,)-226(Gillette)-226(WB.)-226(Effect)-226(of)-226(a)-226(local)-226(germicide)-226(on)]TJ 1.75 -1.208 Td [(the)-286(occurrence)-286(of)-286(bacteremia)-286(during)-286(subgingival)-286(scaling.)]TJ /T1_1 1 Tf 23.193 0 Td [(J)-286(Periodontol)]TJ /T1_0 1 Tf 5.508 0 Td (.)Tj -28.702 -1.208 Td (1982;53:172\226179.)Tj -1.75 -1.208 Td [(69.)-500(Rogosa)-233(M,)-233(Hampp)-233(EG,)-233(Nevin)-233(TA,)-233(Wagner)-233(HN)-233(Jr,)-233(Driscoll)-233(EJ,)-233(Baer)-233(PN.)]TJ 1.75 -1.208 Td [(Blood)-408(sampling)-408(and)-408(cultural)-408(studies)-408(in)-408(the)-408(detection)-408(of)-408(postoperative)]TJ T* (bacteremias.)Tj /T1_1 1 Tf 5.359 0 Td [(J)-333(Am)-333(Dent)-333(Assoc)]TJ /T1_0 1 Tf 7.053 0 Td [(.)-333(1960;60:171\226180.)]TJ -14.162 -1.208 Td [(70.)-500(Bandt)-431(CL,)-431(Korn)-431(NA,)-431(Schaffer)-431(EM.)-431(Bacteremias)-431(from)-431(ultrasonic)-431(and)]TJ 1.75 -1.208 Td [(hand)-333(instrumentation.)]TJ /T1_1 1 Tf 9.138 0 Td [(J)-333(Periodontol)]TJ /T1_0 1 Tf 5.555 0 Td [(.)-333(1964;35:214)-120(\226215.)]TJ 0.0023 Tc -16.441 -1.208 Td [(71.)-502(De)-555(Leo)-555(AA,)-555(Schoenknecht)-555(FD,)-555(Anderson)-555(MW,)-555(Peterson)-555(JC.)-555(The)]TJ 0 Tc 1.748 -1.208 Td [(incidence)-234(of)-234(bacteremia)-234(following)-234(oral)-234(prophylaxis)-234(on)-234(pediatric)-234(patients.)]TJ /T1_1 1 Tf T* [(Oral)-333(Surg)-333(Oral)-333(Med)-333(Oral)-333(Pathol)]TJ /T1_0 1 Tf 13.665 0 Td [(.)-333(1974;37:36)-120(\226)-120(45.)]TJ -15.415 -1.208 Td [(72.)-500(Barco)-282(CT.)-282(Prevention)-282(of)-282(infective)-282(endocarditis:)-282(a)-282(review)-282(of)-282(the)-282(medical)]TJ 1.75 -1.208 Td [(and)-333(dental)-333(literature.)]TJ /T1_1 1 Tf 8.747 0 Td [(J)-333(Periodontol)]TJ /T1_0 1 Tf 5.555 0 Td [(.)-333(1991;62:510)-120(\226523.)]TJ -16.052 -1.208 Td [(73.)-500(Bayliss)-281(R,)-281(Clarke)-281(C,)-281(Oakley)-281(C,)-281(Somerville)-281(W,)-281(Whitfield)-281(AG.)-281(The)-281(teeth)]TJ 1.75 -1.208 Td [(and)-333(infective)-333(endocarditis.)]TJ /T1_1 1 Tf 11.08 0 Td [(Br)-333(Heart)-333(J)]TJ /T1_0 1 Tf 4.443 0 Td [(.)-333(1983;50:506)-120(\226512.)]TJ -17.273 -1.208 Td [(74.)-500(Hirsh)-301(HL,)-301(Vivino)-301(JJ,)-301(Merril)-301(A,)-301(Dowling)-301(HF.)-301(Effect)-301(of)-301(prophylactically)]TJ 1.75 -1.208 Td [(administered)-295(penicillin)-295(on)-295(incidence)-295(of)-295(bacteremia)-295(following)-295(extraction)]TJ T* [(of)-333(teeth.)]TJ /T1_1 1 Tf 3.693 0 Td [(Arch)-333(Intern)-333(Med)]TJ /T1_0 1 Tf 6.831 0 Td [(.)-333(1948;81:868)-120(\226)-120(878.)]TJ -12.274 -1.208 Td [(75.)-500(Shanson)-381(DC,)-381(Akash)-381(S,)-381(Harris)-381(M,)-381(Tadayon)-381(M.)-381(Erythromycin)-381(stearate,)]TJ 1.75 -1.208 Td [(1.5)-345(g,)-345(for)-345(the)-345(oral)-345(prophylaxis)-345(of)-345(streptococcal)-345(bacteraemia)-345(in)-345(patients)]TJ T* [(undergoing)-276(dental)-276(extraction:)-276(efficacy)-276(and)-276(tolerance.)]TJ /T1_1 1 Tf 21.512 0 Td 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[(Br)-333(Dent)-333(J)]TJ /T1_0 1 Tf 4.054 0 Td [(.)-333(1987;162:179)-120(\226182.)]TJ -17.774 -1.242 Td [(77.)-500(Hall)-248(G,)-248(Heimdahl)-248(A,)-248(Nord)-248(CE.)-248(Effects)-248(of)-248(prophylactic)-248(administration)-248(of)]TJ 1.75 -1.242 Td [(cefaclor)-523(on)-523(transient)-523(bacteremia)-523(after)-523(dental)-523(extraction.)]TJ /T1_1 1 Tf 24.238 0 Td [(Eur)-523(J)-523(Clin)]TJ -24.238 -1.242 Td [(Microbiol)-333(Infect)-333(Dis)]TJ /T1_0 1 Tf 8.332 0 Td [(.)-333(1995;15:646)-120(\226)-120(649.)]TJ -10.082 -1.242 Td [(78.)-500(Hall)-537(G,)-537(Heimdahl)-537(A,)-537(Nord)-537(CE.)-537(Bacteremia)-537(after)-537(oral)-537(surgery)-537(and)]TJ 1.75 -1.242 Td [(antibiotic)-436(prophylaxis)-436(for)-436(endocarditis.)]TJ /T1_1 1 Tf 16.549 0 Td [(Clin)-436(Infect)-436(Dis)]TJ /T1_0 1 Tf 6.262 0 Td [(.)-436(1999;29:1\226)-120(8;)]TJ -22.811 -1.242 Td [(quiz)-333(9)-120(\22610.)]TJ -1.75 -1.242 Td 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[(Am)-286(J)-286(Med)]TJ /T1_0 1 Tf 4.125 0 Td (.)Tj -28.701 -1.242 Td (1990;88:131\226136.)Tj -1.75 -1.242 Td [(85.)-500(van)-329(der)-329(Meer)-329(JT,)-329(Thompson)-329(J,)-329(Valkenburg)-329(HA,)-329(Michel)-329(MF.)-329(Epidemi-)]TJ 1.75 -1.242 Td [(ology)-356(of)-356(bacterial)-356(endocarditis)-356(in)-356(The)-356(Netherlands,)-356(II:)-356(antecedent)-356(pro-)]TJ 0 -1.242 TD [(cedures)-247(and)-247(use)-247(of)-247(prophylaxis.)]TJ /T1_1 1 Tf 12.871 0 Td [(Arch)-247(Intern)-247(Med)]TJ /T1_0 1 Tf 6.659 0 Td [(.)-247(1992;152:1869)-120(\2261873.)]TJ -21.28 -1.242 Td [(86.)-500(Van)-534(der)-534(Meer)-534(JT,)-534(Van)-534(Wijk)-534(W,)-534(Thompson)-534(J,)-534(Vandenbroucke)-534(JP,)]TJ 1.75 -1.242 Td [(Valkenburg)-515(HA,)-515(Michel)-515(MF.)-515(Efficacy)-515(of)-515(antibiotic)-515(prophylaxis)-515(for)]TJ 0 -1.242 TD [(prevention)-333(of)-333(native-valve)-333(endocarditis.)]TJ /T1_1 1 Tf 16.523 0 Td (Lancet)Tj /T1_0 1 Tf 2.722 0 Td [(.)-333(1992;339:135\226139.)]TJ -20.995 -1.242 Td [(87.)-500(van)-370(der)-370(Meer)-370(JT,)-370(van)-370(Wijk)-370(W,)-370(Thompson)-370(J,)-370(Valkenburg)-370(HA,)-370(Michel)]TJ 1.75 -1.242 Td [(MF.)-357(Awareness)-357(of)-357(need)-357(and)-357(actual)-357(use)-357(of)-357(prophylaxis:)-357(lack)-357(of)-357(patient)]TJ T* [(compliance)-463(in)-463(the)-463(prevention)-463(of)-463(bacterial)-463(endocarditis.)]TJ /T1_1 1 Tf 23.544 0 Td [(J)-463(Antimicrob)]TJ -23.544 -1.242 Td (Chemother)Tj /T1_0 1 Tf 4.444 0 Td [(.)-333(1992;29:187\226194.)]TJ -6.194 -1.242 Td [(88.)-500(Duval)-272(X,)-272(Alla)-272(F,)-272(Hoen)-272(B,)-272(Danielou)-272(F,)-272(Larrieu)-272(S,)-272(Delahaye)-272(F,)-272(Leport)-272(C,)]TJ 1.75 -1.242 Td [(Briancon)-356(S.)-356(Estimated)-356(risk)-356(of)-356(endocarditis)-356(in)-356(adults)-356(with)-356(predisposing)]TJ T* [(cardiac)-376(conditions)-376(undergoing)-376(dental)-376(procedures)-376(with)-376(or)-376(without)-376(anti-)]TJ T* [(biotic)-333(prophylaxis.)]TJ /T1_1 1 Tf 7.916 0 Td [(Clin)-333(Infect)-333(Dis)]TJ /T1_0 1 Tf 6.055 0 Td [(.)-333(2006;42:e102\226)-120(e107.)]TJ -15.721 -1.241 Td [(89.)-500(Starkebaum)-359(M,)-359(Durack)-359(D,)-359(Beeson)-359(P.)-359(The)-359(\223incubation)-359(period\224)-359(of)-359(sub-)]TJ 1.75 -1.241 Td [(acute)-333(bacterial)-333(endocarditis.)]TJ /T1_1 1 Tf 11.69 0 Td [(Yale)-333(J)-333(Biol)-333(Med)]TJ /T1_0 1 Tf 6.665 0 Td [(.)-333(1977;50:49)-120(\22658.)]TJ -20.105 -1.241 Td [(90.)-500(Steckelberg)-450(JM,)-450(Wilson)-450(WR.)-450(Risk)-450(factors)-450(for)-450(infective)-450(endocarditis.)]TJ /T1_1 1 Tf 1.75 -1.241 Td [(Infect)-333(Dis)-333(Clin)-333(North)-333(Am)]TJ /T1_0 1 Tf 10.388 0 Td [(.)-333(1993;7:9)-120(\22619.)]TJ -12.138 -1.241 Td [(91.)-500(Pallasch)-462(TJ,)-462(Wahl)-462(MJ.)-462(Focal)-462(infection:)-462(new)-462(age)-462(or)-462(ancient)-462(history?)]TJ /T1_1 1 Tf 1.75 -1.241 Td [(Endodontic)-333(Topics)]TJ /T1_0 1 Tf 7.611 0 Td [(.)-333(2003;4:32\226)-120(45.)]TJ -9.361 -1.241 Td [(92.)-500(Idsoe)-450(O,)-450(Guthe)-450(T,)-450(Willcox)-450(RR,)-450(de)-450(Weck)-450(AL.)-450(Nature)-450(and)-450(extent)-450(of)]TJ 1.75 -1.241 Td [(penicillin)-269(side-reactions,)-269(with)-269(particular)-269(reference)-269(to)-269(fatalities)-269(from)-269(ana-)]TJ 0 -1.241 TD [(phylactic)-333(shock.)]TJ /T1_1 1 Tf 6.915 0 Td [(Bull)-333(World)-333(Health)-333(Organ)]TJ /T1_0 1 Tf 10.499 0 Td [(.)-333(1968;38:159)-120(\226188.)]TJ -19.164 -1.241 Td [(93.)-500(Ahlstedt)-409(S.)-409(Penicillin)-409(allergy:)-409(can)-409(the)-409(incidence)-409(be)-409(reduced?)]TJ /T1_1 1 Tf 27.507 0 Td (Allergy)Tj /T1_0 1 Tf 2.944 0 Td (.)Tj -28.701 -1.241 Td (1984;39:151\226164.)Tj -1.75 -1.241 Td [(94.)-500(Agha)-473(Z,)-473(Lofgren)-473(RP,)-473(VanRuiswyk)-473(JV.)-473(Is)-473(antibiotic)-473(prophylaxis)-473(for)]TJ 0.0076 Tc 1.75 -1.241 Td [(bacterial)-560(endocarditis)-560(cost-effective?)]TJ /T1_1 1 Tf 16.17 0 Td [(Med)-560(Decis)-560(Making)]TJ /T1_0 1 Tf 8.336 0 Td [(.)-560(2005;25:)]TJ 0 Tc -24.506 -1.241 Td [(308)-120(\226320.)]TJ -1.75 -1.241 Td [(95.)-500(Kelkar)-479(PS,)-479(Li)-479(JT.)-479(Cephalosporin)-479(allergy.)]TJ /T1_1 1 Tf 19.705 0 Td [(N)-479(Engl)-479(J)-479(Med)]TJ /T1_0 1 Tf 6.213 0 Td [(.)-479(2001;345:)]TJ -24.168 -1.241 Td [(804)-120(\226)-120(809.)]TJ -1.75 -1.241 Td [(96.)-500(Guay)-345(DR,)-345(Patterson)-345(DR,)-345(Seipman)-345(N,)-345(Craft)-345(JC.)-345(Overview)-345(of)-345(the)-345(toler-)]TJ 1.75 -1.241 Td [(ability)-362(profile)-362(of)-362(clarithromycin)-362(in)-362(preclinical)-362(and)-362(clinical)-362(trials.)]TJ /T1_1 1 Tf 26.839 0 Td (Drug)Tj -26.839 -1.241 Td (Saf)Tj /T1_0 1 Tf 1.278 0 Td [(.)-333(1993;8:350)-120(\226364.)]TJ -3.028 -1.241 Td [(97.)-500(Mazur)-411(N,)-411(Greenberger)-411(PA,)-411(Regalado)-411(J.)-411(Clindamycin)-411(hypersensitivity)]TJ 1.75 -1.241 Td [(appears)-333(to)-333(be)-333(rare.)]TJ /T1_1 1 Tf 7.912 0 Td [(Ann)-333(Allergy)-333(Asthma)-333(Immunol)]TJ /T1_0 1 Tf 12.109 0 Td [(.)-333(1999;82:443\226)-120(445.)]TJ -21.771 -1.241 Td [(98.)-500(Bombassaro)-400(AM,)-400(Wetmore)-400(SJ,)-400(John)-400(MA.)]TJ /T1_1 1 Tf 19.623 0 Td [(Clostridium)-400(difficile)]TJ /T1_0 1 Tf 8.636 0 Td (colitis)Tj -26.509 -1.241 Td [(following)-533(antibiotic)-533(prophylaxis)-533(for)-533(dental)-533(procedures.)]TJ /T1_1 1 Tf 23.832 0 Td [(J)-533(Can)-533(Dent)]TJ -23.832 -1.241 Td (Assoc)Tj /T1_0 1 Tf 2.333 0 Td [(.)-333(2001;67:20)-120(\22622.)]TJ -4.083 -1.241 Td [(99.)-500(Tleyjeh)-270(IM,)-270(Steckelberg)-270(JM,)-270(Murad)-270(HS,)-270(Anavekar)-270(NS,)-270(Ghomrawi)-270(HM,)]TJ 1.75 -1.241 Td [(Mirzoyev)-461(Z,)-461(Moustafa)-461(SE,)-461(Hoskin)-461(TL,)-461(Mandrekar)-461(JN,)-461(Wilson)-461(WR,)]TJ 0.05 Tc T* [(Baddour)-732(LM.)-732(Temporal)-732(trends)-732(in)-732(infective)-732(endocarditis:)-732(a)]TJ 0 Tc T* [(population-based)-434(study)-434(in)-434(Olmsted)-434(County,)-434(Minnesota.)]TJ /T1_1 1 Tf 23.491 0 Td (JAMA)Tj /T1_0 1 Tf 2.499 0 Td [(.)-434(2005;)]TJ -25.99 -1.241 Td (293:3022\2263028.)Tj -2.25 -1.241 Td [(100.)-500(Griffin)-418(MR,)-418(Wilson)-418(WR,)-418(Edwards)-418(WD,)-418(O\222Fallon)-418(WM,)-418(Kurland)-418(LT.)]TJ 2.25 -1.241 Td [(Infective)-259(endocarditis:)-259(Olmsted)-259(County,)-259(Minnesota,)-259(1950)-259(through)-259(1981.)]TJ /T1_1 1 Tf T* (JAMA)Tj /T1_0 1 Tf 2.499 0 Td [(.)-333(1985;254:1199)-120(\2261202.)]TJ -4.749 -1.241 Td [(101.)-500(Durack)-514(DT,)-514(Petersdorf)-514(RG.)-514(Changes)-514(in)-514(the)-514(epidemiology)-514(of)-514(endo-)]TJ 2.25 -1.241 Td [(carditis.)-297(Paper)-297(presented)-297(at:)-297(Infective)-297(Endocarditis:)-297(An)-297(American)-297(Heart)]TJ T* [(Association)-319(Symposium;)-319(held)-319(May)-319(14)-120(\22615,)-319(1976.)-319(In:)-319(AHA)-319(Monograph)]TJ T* [(#52,)-333(1977.)]TJ 32.15 89.4 Td [(102.)-500(Delahaye)-440(F,)-440(Goulet)-440(V,)-440(Lacassin)-440(F,)-440(et)-440(al.)-440(Characteristics)-440(of)-440(infective)]TJ 2.25 -1.209 Td [(endocarditis)-319(in)-319(France)-319(in)-319(1991:)-319(a)-319(1-year)-319(survey.)]TJ /T1_1 1 Tf 19.912 0 Td [(Eur)-319(Heart)-319(J)]TJ /T1_0 1 Tf 4.916 0 Td [(.)-319(1995;16:)]TJ -24.827 -1.209 Td [(394)-120(\226)-120(401.)]TJ -2.25 -1.209 Td [(103.)-500(Hoen)-465(B,)-465(Alla)-465(F,)-465(Selton-Suty)-465(C,)-465(Beguinot)-465(I,)-465(Bouvet)-465(A,)-465(Briancon)-465(S,)]TJ 2.25 -1.209 Td [(Casalta)-325(JP,)-325(Danchin)-325(N,)-325(Delahaye)-325(F,)-325(Etienne)-325(J,)-325(Le)-325(Moing)-325(V,)-325(Leport)-325(C,)]TJ 0 -1.209 TD [(Mainardi)-373(JL,)-373(Ruimy)-373(R,)-373(Vandenesch)-373(F;)-373(Association)-373(pour)-373(l\222Etude)-373(et)-373(la)]TJ 0.0318 Tc T* [(Prevention)-584(de)-584(l\222Endocardite)-584(Infectieuse)-584(\(AEPEI\))-584(Study)-584(Group.)]TJ 0 Tc T* [(Changing)-301(profile)-301(of)-301(infective)-301(endocarditis:)-301(results)-301(of)-301(a)-301(1-year)-301(survey)-301(in)]TJ T* (France.)Tj /T1_1 1 Tf 3.304 0 Td (JAMA)Tj /T1_0 1 Tf 2.499 0 Td [(.)-333(2002;288:75\226)-120(81.)]TJ -8.053 -1.209 Td [(104.)-500(Mylonakis)-337(E,)-337(Calderwood)-337(SB.)-337(Infective)-337(endocarditis)-337(in)-337(adults.)]TJ /T1_1 1 Tf 28.309 0 Td [(N)-337(Engl)]TJ -26.059 -1.209 Td [(J)-333(Med)]TJ /T1_0 1 Tf 2.554 0 Td [(.)-333(2001;345:1318)-120(\2261330.)]TJ -4.804 -1.209 Td [(105.)-500(Gersony)-254(WM,)-254(Hayes)-254(CJ,)-254(Driscoll)-254(DJ,)-254(Keane)-254(JF,)-254(Kidd)-254(L,)-254(O\222Fallon)-254(WM,)]TJ 2.25 -1.209 Td [(Pieroni)-239(DR,)-239(Wolfe)-239(RR,)-239(Weidman)-239(WH.)-239(Bacterial)-239(endocarditis)-239(in)-239(patients)]TJ T* [(with)-442(aortic)-442(stenosis,)-442(pulmonary)-442(stenosis,)-442(or)-442(ventricular)-442(septal)-442(defect.)]TJ /T1_1 1 Tf 0 -1.209 TD (Circulation)Tj /T1_0 1 Tf 4.612 0 Td [(.)-333(1993;87\(suppl\):I-121\226I-126.)]TJ -6.862 -1.209 Td [(106.)-500(Wilson)-220(WR,)-220(Jaumin)-220(PM,)-220(Danielson)-220(GK,)-220(Giuliani)-220(ER,)-220(Washington)-220(JA)-220(II,)]TJ 2.25 -1.209 Td [(Geraci)-512(JE.)-512(Prosthetic)-512(valve)-512(endocarditis.)]TJ /T1_1 1 Tf 17.778 0 Td [(Ann)-512(Intern)-512(Med)]TJ /T1_0 1 Tf 6.855 0 Td [(.)-512(1975;82:)]TJ -24.633 -1.209 Td (751\226756.)Tj -2.25 -1.209 Td [(107.)-500(Baddour)-464(LM,)-464(Wilson)-464(WR.)-464(Infections)-464(of)-464(prosthetic)-464(valves)-464(and)-464(other)]TJ 2.25 -1.209 Td [(cardiovascular)-523(devices.)-523(In:)-523(Mandell)-523(GL,)-523(Bennett)-523(JE,)-523(Dolin)-523(R,)-523(eds.)]TJ /T1_1 1 Tf 0 -1.209 TD [(Mandell,)-341(Douglas,)-341(and)-341(Bennett\222s)-341(Principles)-341(and)-341(Practice)-341(of)-341(Infectious)]TJ 0.014 Tc T* (Diseases.)Tj /T1_0 1 Tf 4.498 0 Td [(Philadelphia,)-567(Pa:)-567(Elsevier)-567(Churchill)-567(Livingstone;)-567(2005:)]TJ 0 Tc -4.498 -1.209 Td (1022\2261044.)Tj 0.0011 Tc -2.25 -1.209 Td [(108.)-501(Baddour)-554(LM,)-554(Wilson)-554(WR,)-554(Bayer)-554(AS,)-554(Fowler)-554(VG)-554(Jr,)-554(Bolger)-554(AF,)]TJ 0 Tc 2.25 -1.209 Td [(Levison)-329(ME,)-329(Ferrieri)-329(P,)-330(Gerber)-329(MA,)-329(Tani)-329(LY,)-329(Gewitz)-329(MH,)-329(Tong)-330(DC,)]TJ T* [(Steckelberg)-473(JM,)-473(Baltimore)-473(RS,)-473(Shulman)-473(ST,)-473(Burns)-473(JC,)-473(Falace)-473(DA,)]TJ T* [(Newburger)-307(JW,)-307(Pallasch)-307(TJ,)-307(Takahashi)-307(M,)-307(Taubert)-307(KA;)-307(Committee)-307(on)]TJ 0 -1.208 TD [(Rheumatic)-550(Fever,)-550(Endocarditis,)-550(and)-550(Kawasaki)-550(Disease;)-550(Council)-550(on)]TJ 0 -1.208 TD [(Cardiovascular)-289(Disease)-289(in)-289(the)-289(Young;)-289(Councils)-289(on)-289(Clinical)-289(Cardiology,)]TJ T* [(Stroke,)-451(and)-451(Cardiovascular)-451(Surgery)-451(and)-451(Anesthesia;)-451(American)-451(Heart)]TJ T* [(Association;)-443(Infectious)-443(Diseases)-443(Society)-443(of)-443(America.)-443(Infective)-443(endo-)]TJ T* [(carditis:)-374(diagnosis,)-374(antimicrobial)-374(therapy,)-374(and)-374(management)-374(of)-374(compli-)]TJ T* 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[(Fowler)-553(VG)-553(Jr;)-553(International)-553(Collaboration)-553(on)-553(Endocarditis)-553(Merged)]TJ 0 Tc 0 -1.208 TD [(Database)-491(Study)-491(Group.)-491(Native)-491(valve)-491(endocarditis)-491(due)-491(to)-491(coagulase-)]TJ T* [(negative)-481(staphylococci:)-481(report)-481(of)-481(99)-481(episodes)-481(from)-481(the)-481(International)]TJ T* [(Collaboration)-307(on)-307(Endocarditis)-307(Merged)-307(Database.)]TJ /T1_1 1 Tf 20.114 0 Td [(Clin)-307(Infect)-307(Dis)]TJ /T1_0 1 Tf 6.003 0 Td [(.)-307(2004;)]TJ -26.117 -1.208 Td (39:1527\2261530.)Tj -2.25 -1.208 Td [(113.)-500(Lalani)-237(T,)-237(Kanafani)-237(ZA,)-237(Chu)-237(VH,)-237(Moore)-237(L,)-237(Corey)-237(GR,)-237(Pappas)-237(P,)-237(Woods)]TJ 2.25 -1.208 Td [(CW,)-344(Cabell)-344(CH,)-344(Hoen)-344(B,)-344(Selton-Suty)-344(C,)-344(Doco-Lecompte)-344(T,)-344(Chirouze)]TJ T* [(C,)-373(Raoult)-373(D,)-373(Miro)-373(JM,)-373(Mestres)-373(CA,)-373(Olaison)-373(L,)-373(Eykyn)-373(S,)-373(Abrutyn)-373(E,)]TJ T* [(Fowler)-293(VG)-293(Jr;)-293(The)-293(International)-293(Collaboration)-293(on)-293(Endocarditis)-293(Merged)]TJ T* [(Database)-325(Study)-325(Group.)-325(Prosthetic)-325(valve)-325(endocarditis)-325(due)-325(to)-325(coagulase-)]TJ T* [(negative)-247(staphylococci:)-247(findings)-247(from)-247(the)-247(International)-247(Collaboration)-247(on)]TJ T* [(Endocarditis)-334(Merged)-334(Database.)]TJ /T1_1 1 Tf 13.083 0 Td [(Eur)-334(J)-334(Clin)-334(Microbiol)-334(Infect)-334(Dis)]TJ /T1_0 1 Tf 13.005 0 Td [(.)-334(2006;)]TJ -26.089 -1.208 Td (25:365\226368.)Tj -2.25 -1.208 Td [(114.)-500(McDonald)-375(JR,)-375(Olaison)-375(L,)-375(Anderson)-375(DJ,)-375(Hoen)-375(B,)-375(Miro)-375(JM,)-375(Eykyn)-375(S,)]TJ 2.25 -1.208 Td [(Abrutyn)-317(E,)-317(Fowler)-317(VG)-317(Jr,)-317(Habib)-317(G,)-317(Selton-Suty)-317(C,)-317(Pappas)-317(PA,)-317(Cabell)]TJ T* [(CH,)-421(Corey)-421(GR,)-421(Marco)-421(F,)-421(Sexton)-421(DJ.)-421(Enterococcal)-421(endocarditis:)-421(107)]TJ 0.0004 Tc T* [(cases)-553(from)-553(the)-553(International)-553(Collaboration)-553(on)-553(Endocarditis)-553(Merged)]TJ 0 Tc T* (Database.)Tj /T1_1 1 Tf 4.248 0 Td [(Am)-333(J)-333(Med)]TJ /T1_0 1 Tf 4.22 0 Td [(.)-333(2005;118:759)-120(\226766.)]TJ -10.718 -1.208 Td [(115.)-500(Sexton)-455(DJ,)-455(Tenenbaum)-455(MJ,)-455(Wilson)-455(WR,)-455(Steckelberg)-455(JM,)-455(Tice)-455(AD,)]TJ 2.25 -1.208 Td [(Gilbert)-264(D,)-264(Dismukes)-264(W,)-264(Drew)-264(RH,)-264(Durack)-264(DT;)-264(Endocarditis)-264(Treatment)]TJ T* [(Consortium)-442(Group.)-442(Ceftriaxone)-442(once)-442(daily)-442(for)-442(four)-442(weeks)-442(compared)]TJ T* [(with)-257(ceftriaxone)-257(plus)-257(gentamicin)-257(once)-257(daily)-257(for)-257(two)-257(weeks)-257(for)-257(treatment)]TJ /T1_2 1 Tf 10 0 0 10 56.1648 752.3835 Tm [(18)-2000(Circulation)]TJ /T1_3 1 Tf 9.724 0 Td [(May)-333(8,)-333(2007)]TJ 0 g ET /GS1 gs BT /T1_4 1 Tf 9 0 0 9 294.7364 32 Tm ( by WARREN WALSH on April 19, 2007 )Tj 0 0 1 rg ET /GS1 gs BT /T1_4 1 Tf 9 0 0 9 223.2585 32 Tm (circ.ahajournals.org)Tj 0 g ET /GS1 gs BT /T1_4 1 Tf 9 0 0 9 155.2727 32 Tm (Downloaded from )Tj ET endstream endobj 318 0 obj<> endobj 319 0 obj<> endobj 320 0 obj[318 0 R] endobj 321 0 obj<> endobj 324 0 obj<>stream q 360 0 0 139 129 259 cm /Im0 Do Q 0 0 0 1 k 1 i /GS0 gs BT /T1_0 1 Tf 0 Tc 0 Tw 0 Ts 100 Tz 0 Tr 7.5 0 0 7.5 73.0398 720.8835 Tm [(of)-481(endocarditis)-481(due)-481(to)-481(penicillin-susceptible)-481(streptococci.)]TJ /T1_1 1 Tf 24.469 0 Td [(Clin)-481(Infect)]TJ -24.469 -1.209 Td (Dis)Tj /T1_0 1 Tf 1.389 0 Td [(.)-333(1998;27:1470)-120(\2261474.)]TJ -3.639 -1.209 Td [(116.)-500(Francioli)-463(P,)-463(Etienne)-463(J,)-463(Hoigne)-463(R,)-463(Thys)-463(JP,)-463(Gerber)-463(A.)-463(Treatment)-463(of)]TJ 2.25 -1.209 Td [(streptococcal)-229(endocarditis)-229(with)-229(a)-229(single)-229(daily)-229(dose)-229(of)-229(ceftriaxone)-229(sodium)]TJ 0 -1.209 TD [(for)-310(4)-310(weeks:)-310(efficacy)-310(and)-310(outpatient)-310(treatment)-310(feasibility.)]TJ /T1_1 1 Tf 23.613 0 Td (JAMA)Tj /T1_0 1 Tf 2.499 0 Td [(.)-310(1992;)]TJ -26.112 -1.209 Td [(267:264)-120(\226267.)]TJ 0.0159 Tc -2.25 -1.209 Td [(117.)-516(Wilson)-569(WR,)-569(Wilkowske)-569(CJ,)-569(Wright)-569(AJ,)-569(Sande)-569(MA,)-569(Geraci)-569(JE.)]TJ 0.0231 Tc 2.25 -1.209 Td [(Treatment)-576(of)-576(streptomycin-susceptible)-576(and)-576(streptomycin-resistant)]TJ 0 Tc 0 -1.209 TD [(enterococcal)-333(endocarditis.)]TJ /T1_1 1 Tf 10.857 0 Td [(Ann)-333(Intern)-333(Med)]TJ /T1_0 1 Tf 6.498 0 Td [(.)-333(1984;100:816)-120(\226)-120(823.)]TJ -19.605 -1.209 Td [(118.)-500(Mansur)-332(AJ,)-332(Dal)-332(Bo)-332(CM,)-332(Fukushima)-332(JT,)-332(Issa)-332(VS,)-332(Grinberg)-332(M,)-332(Pomer-)]TJ 2.25 -1.209 Td [(antzeff)-431(PM.)-431(Relapses,)-431(recurrences,)-431(valve)-431(replacements,)-431(and)-431(mortality)]TJ T* [(during)-267(the)-267(long-term)-267(follow-up)-267(after)-267(infective)-267(endocarditis.)]TJ /T1_1 1 Tf 24.057 0 Td [(Am)-267(Heart)-267(J)]TJ /T1_0 1 Tf 4.643 0 Td (.)Tj -28.7 -1.209 Td [(2001;141:78)-120(\226)-120(86.)]TJ -2.25 -1.209 Td [(119.)-500(Baddour)-443(LM.)-443(Twelve-year)-443(review)-443(of)-443(recurrent)-443(native-valve)-443(infective)]TJ 2.25 -1.209 Td [(endocarditis:)-468(a)-468(disease)-468(of)-468(the)-468(modern)-468(antibiotic)-468(era.)]TJ /T1_1 1 Tf 22.599 0 Td [(Rev)-468(Infect)-468(Dis)]TJ /T1_0 1 Tf 6.101 0 Td (.)Tj -28.7 -1.209 Td (1988;10:1163\2261170.)Tj -2.25 -1.209 Td [(120.)-500(Chu)-445(VH,)-445(Sexton)-445(DJ,)-445(Cabell)-445(CH,)-445(Reller)-445(LB,)-445(Pappas)-445(PA,)-445(Singh)-445(RK,)]TJ 2.25 -1.209 Td [(Fowler)-507(VG)-507(Jr,)-507(Corey)-507(GR,)-507(Aksoy)-507(O,)-507(Woods)-507(CW.)-507(Repeat)-507(infective)]TJ T* [(endocarditis:)-438(differentiating)-438(relapse)-438(from)-438(reinfection.)]TJ /T1_1 1 Tf 22.436 0 Td [(Clin)-438(Infect)-438(Dis)]TJ /T1_0 1 Tf 6.265 0 Td (.)Tj -28.702 -1.209 Td [(2005;41:406)-120(\226)-120(409.)]TJ 0.0083 Tc -2.25 -1.209 Td [(121.)-508(Welton)-561(DE,)-561(Young)-561(JB,)-561(Gentry)-561(WO,)-561(Raizner)-561(AE,)-561(Alexander)-561(JK,)]TJ 0 Tc 2.25 -1.209 Td [(Chahine)-404(RA,)-404(Miller)-404(RR.)-404(Recurrent)-404(infective)-404(endocarditis:)-404(analysis)-404(of)]TJ T* [(predisposing)-276(factors)-276(and)-276(clinical)-276(features.)]TJ /T1_1 1 Tf 17.014 0 Td [(Am)-276(J)-276(Med)]TJ /T1_0 1 Tf 4.105 0 Td [(.)-276(1979;66:932\226938.)]TJ 0.003 Tc -23.369 -1.209 Td [(122.)-503(Levison)-556(ME,)-556(Kaye)-556(D,)-556(Mandell)-556(GL,)-556(Hook)-556(EW.)-556(Characteristics)-556(of)]TJ 0 Tc 2.25 -1.209 Td [(patients)-355(with)-355(multiple)-355(episodes)-355(of)-355(bacterial)-355(endocarditis.)]TJ /T1_1 1 Tf 23.568 0 Td (JAMA)Tj /T1_0 1 Tf 2.499 0 Td [(.)-355(1970;)]TJ -26.067 -1.209 Td (211:1355\2261357.)Tj -2.25 -1.209 Td [(123.)-500(Renzulli)-267(A,)-267(Carozza)-267(A,)-267(Romano)-267(G,)-267(De)-267(Feo)-267(M,)-267(Della)-267(Corte)-267(A,)-267(Gregorio)]TJ 2.25 -1.209 Td [(R,)-335(Cotrufo)-335(M.)-335(Recurrent)-335(infective)-335(endocarditis:)-335(a)-335(multivariate)-335(analysis)]TJ T* [(of)-333(21)-333(years)-333(of)-333(experience.)]TJ /T1_1 1 Tf 11.022 0 Td [(Ann)-333(Thorac)-333(Surg)]TJ /T1_0 1 Tf 7.055 0 Td [(.)-333(2001;72:39)-120(\226)-120(43.)]TJ -20.327 -1.209 Td [(124.)-500(Erbel)-380(R,)-380(Liu)-380(F,)-380(Ge)-380(J,)-380(Kupferwasser)-380(I.)-380(Identification)-380(of)-380(high-risk)-380(sub-)]TJ 2.25 -1.209 Td [(groups)-344(in)-344(infective)-344(endocarditis)-344(and)-344(the)-344(role)-344(of)-344(echocardiography.)]TJ /T1_1 1 Tf 27.45 0 Td (Eur)Tj -27.45 -1.209 Td [(Heart)-333(J)]TJ /T1_0 1 Tf 3.11 0 Td [(.)-333(1995;16:588)-120(\226)-120(602.)]TJ -5.36 -1.209 Td [(125.)-500(Kaplan)-359(EL,)-359(Rich)-359(H,)-359(Gersony)-359(W,)-359(Manning)-359(J.)-359(A)-359(collaborative)-359(study)-359(of)]TJ 2.25 -1.209 Td [(infective)-371(endocarditis)-371(in)-371(the)-371(1970s:)-371(emphasis)-371(on)-371(infections)-371(in)-371(patients)]TJ 0.0045 Tc T* [(who)-557(have)-557(undergone)-557(cardiovascular)-557(surgery.)]TJ /T1_1 1 Tf 19.87 0 Td (Circulation)Tj /T1_0 1 Tf 4.662 0 Td [(.)-557(1979;59:)]TJ 0 Tc -24.532 -1.209 Td (327\226335.)Tj -2.25 -1.209 Td [(126.)-500(Coward)-425(K,)-425(Tucker)-425(N,)-425(Darville)-425(T.)-425(Infective)-425(endocarditis)-425(in)-425(Arkansan)]TJ 0.0076 Tc 2.25 -1.209 Td [(children)-560(from)-560(1990)-560(through)-560(2002.)]TJ /T1_1 1 Tf 15.595 0 Td [(Pediatr)-560(Infect)-560(Dis)-560(J)]TJ /T1_0 1 Tf 8.92 0 Td [(.)-560(2003;22:)]TJ 0 Tc -24.515 -1.209 Td [(1048)-120(\2261052.)]TJ -2.25 -1.209 Td [(127.)-500(Saiman)-375(L,)-375(Prince)-375(A,)-375(Gersony)-375(WM.)-375(Pediatric)-375(infective)-375(endocarditis)-375(in)]TJ 2.25 -1.209 Td [(the)-333(modern)-333(era.)]TJ /T1_1 1 Tf 6.747 0 Td [(J)-333(Pediatr)]TJ /T1_0 1 Tf 3.777 0 Td [(.)-333(1993;122:847\226)-120(853.)]TJ -12.774 -1.209 Td [(128.)-500(Dodo)-424(H,)-424(Child)-424(JS.)-424(Infective)-424(endocarditis)-424(in)-424(congenital)-424(heart)-424(disease.)]TJ /T1_1 1 Tf 2.25 -1.209 Td [(Cardiol)-333(Clin)]TJ /T1_0 1 Tf 5.168 0 Td [(.)-333(1996;14:383\226392.)]TJ -7.418 -1.209 Td [(129.)-500(Martin)-348(JM,)-348(Neches)-348(WH,)-348(Wald)-348(ER.)-348(Infective)-348(endocarditis:)-348(35)-348(years)-348(of)]TJ 2.25 -1.209 Td [(experience)-333(at)-333(a)-333(children\222s)-333(hospital.)]TJ /T1_1 1 Tf 14.578 0 Td [(Clin)-333(Infect)-333(Dis)]TJ /T1_0 1 Tf 6.055 0 Td [(.)-333(1997;24:669)-120(\226)-120(675.)]TJ -22.883 -1.209 Td [(130.)-500(Parras)-332(F,)-332(Bouza)-332(E,)-332(Romero)-332(J,)-332(Buzon)-332(L,)-332(Quero)-332(M,)-332(Brito)-332(J,)-332(Vellibre)-332(D.)]TJ 2.25 -1.209 Td [(Infectious)-333(endocarditis)-333(in)-333(children.)]TJ /T1_1 1 Tf 14.524 0 Td [(Pediatr)-333(Cardiol)]TJ /T1_0 1 Tf 6.445 0 Td [(.)-333(1990;11:77\226)-120(81.)]TJ -23.219 -1.209 Td [(131.)-500(Takeda)-482(S,)-482(Nakanishi)-482(T,)-482(Nakazawa)-482(M.)-482(A)-482(28-year)-482(trend)-482(of)-482(infective)]TJ 2.25 -1.209 Td [(endocarditis)-300(associated)-300(with)-300(congenital)-300(heart)-300(diseases:)-300(a)-300(single)-300(institute)]TJ T* (experience.)Tj /T1_1 1 Tf 4.914 0 Td [(Pediatr)-333(Int)]TJ /T1_0 1 Tf 4.444 0 Td [(.)-333(2005;47:392\226396.)]TJ 0.0083 Tc -11.608 -1.209 Td [(132.)-508(Ferrieri)-561(P,)-561(Gewitz)-561(MH,)-561(Gerber)-561(MA,)-561(Newburger)-561(JW,)-561(Dajani)-561(AS,)]TJ 0 Tc 2.25 -1.209 Td 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