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Top Six Paediatric Picks of 2014 Prevention is Key Kathryn Leccese Sun Peaks Feb 2015.

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Presentation on theme: "Top Six Paediatric Picks of 2014 Prevention is Key Kathryn Leccese Sun Peaks Feb 2015."— Presentation transcript:

1 Top Six Paediatric Picks of 2014 Prevention is Key Kathryn Leccese Sun Peaks Feb 2015

2 6 picks at sun peaks in paediatrics Antibiotic Stewardship: bacteria gone viral! My brain is fried: cell phone use in kids and teens. PRAM scores; nothing to do with babies. Autism prevalence aka pregnancy is hard enough Cute chubby baby begets pudgy preteen Kids having kids

3 Objectives  Prevention in paediatrics is paramount  Review some of the top articles in research that came out in the past year; 2014  Prevention of an antibiotic apocalypse  Discuss potential anticipatory guidance for cell phone use in children ; and adults  Introduce new strategies for asthma stratification in order to hopefully send kids home sooner  Review some new literature on autism links in order to better guide your advice to pregnant patients  Review potential age targets for risk of obesity in children  Help discussions with teenagers or prevent pregnancy

4 Bugs behaving badly Not all bugs need drugs 70-80% of paediatric fevers are due to viruses and not bacteria Antibiotics in livestock … its not all us According to the National Resource Defense Council 80% of antibiotic use in the USA is used to promote livestock use GMOs Few drugs aside from anitmicrobials can lay claim to provide cure for disease This life saving impacts are sill observed everyday but may be in peril in the future

5 Selected Bacteria/Resistance Combinations BacteriumResistance/decreased susceptibility to: Eschericia coli3 rd generation cephalosporins, fluroquinolones Klebsiella pneumonia3 rd generation cephalosporins Staphylococcus aureusMethicillin Streptococcus pneumoniaPenicillin Nontyphoidal SalmonellaFluoroquinolones Shigella speciesFluoroquinolones Neisseiria gonorrhoeae3 rd generation cephalosporins WHO Antimicrobial Resistance Global Report on Surveillance 2014

6 Resistance for Nine Selected Bacteria/Antibacterial Drug Combinations, 2013 WHO Antimicrobial Resistance Global Report on Surveillance 2014

7 Neisseria Gonorrhoeae Detection of decreased susceptibility to 3rd generation cephalosporin and treatment failures up to 2010 WHO Antimicrobial Resistance Global Report on Surveillance 2014

8 WHO report 1. High proportions of resistance were reported in all regions to common treatments for bacteria causing infections in both healthcare settings and in the community 2. Antibacterial resistance has a negative effect on patient outcomes and health expenditures 3. Treatment options for common infections are running out 4. Despite limitations, the report demonstrates worldwide magnitude of ABR and surveillance gaps 5. Gaps are largest where health systems are weak 6. There is no agreement on surveillance standards: 1. What samples and information to collect 2. How to analyze samples 3. How to compile and share data 7. Obtained national data was usually based on proportions of resistant bacteria rather than proportions of resistant bacteria causing specific diseases or affecting defined populations 8. The report provides a benchmark for future surveillance progress

9 Managing Antimicrobial stewardship in daily practice: Managing an important resource CPS 2014  Use clinical judgment and test judiciously  Based on age, history and physical exam  If serious infection suspected (meningitis, bacteremia etc) appropriate cultures should be taken and effective abx BASED on potential pathogens  Results of cultures should tailor therapy or stop antimicrobial therapy  Office based difficult; follow up is key  Pharyngitis with non viral symptoms:  Throat swab for GAS to confirm streptococcal pharyngitis; wait hr for culture is reasonable in a child that is not severely ill. CPS positions statement Antimicrobial steward ship in daily practice. May 2014

10 Managing Antimicrobial stewardship in daily practice:Manageing an important resource CPS 2014  AOM: accuracy of diagnosis is paramount  Fluid behind inflamed tympanic membrane in a child who has acute ear pain is paramount  If older than 6 mo of age, unilateral and uncomplicated with mild symptoms  Treatment with analgesics and follow up in hrs is reasonable  Persistent symptoms --- bacterial etiology more likely  Lobar pneumonia: confirm diagnosis with X-ray  Recommended before starting antibiotics  If pneumonic infiltrate Is not observed or consistent with bronchiolitis careful follow up is required; not antimicrobials  If viral illness suspected; more prudent to have careful follow up than antibiotics CPS positions statement Antimicrobial steward ship in daily practice. May 2014

11 Treat infection, not contamination  To prevent contamination urine samples collect samples appropriately  Catheter or clean catch midstream  Even in newborns… bags are bad  Diagnosis of UTI requires signs AND some laboratory evidence then culture positive  Treatment of positive cultures if there are no signs of infection is incorrect  Do not take throat swabs if no signs of infection; will be treating colonized patients  Presence of MRSA in nasal or rectal specimens should not routinely start antibiotic regimens for decolonization CPS positions statement Antimicrobial steward ship in daily practice. May 2014

12 Take a careful history of potential antibiotic side effects and if possible confirm an antimicrobial allergy  IgE mediated allergy: urticarial, pruritus, bronchospasm, angioedema or hypotension within 1h of drug administration  Confirmed or disprove allergies by an allergist  History of Ig E penicillin allergy in a parent is not a reason for avoidance in a child  Cross reactivity with cepahlosporins is very low (2%)  History of SJS or TENS attributed to an antibiotic is a reason to avoid related antibiotics in the future CPS positions statement Antimicrobial steward ship in daily practice. May 2014

13  Most common side effects of using an antibiotic are non urticarial maculopapular rashes of GI symptoms  Most are viral or idiosyncratic reactions to the drug NOT an allergy  Therefore it can be given to the child in the future  Allowing the use of antibiotics with a narrower spectrum of activity

14 Laboratories should produce local, age- specific antibiograms to guide antibiotic choices for selected infections  Local antibiogram is compilation of susceptibility patters for common isolated bacteria



17 Managing Antimicrobial stewardship in daily practice:Manageing an important resource CPS 2014  Narrow the spectrum of antimicrobials when a causative organism is identified  Optimize dosing of antimicrobials to obtain maximal benefit  Use higher end of the recommended dose range for specific infection  Aminoglycosides have “dose dependent killing” maximal effect with high initial dose & less frequent dosing;  q24 is recommended over the q8h dosing in all children (not neonates)  Oral beta-lactams have short half life and have “time dependent killing”,  non serious infection (AOM) twice daily dosing is sufficient  more serious infections (pneumonia) 3-4 times a day dosing is used

18 Use the shortest recommended course of therapy for uncomplicated infection  Shorter course are associated with fewer adverse events and less development of resistance  The optimal duration for most infections is not known  Guidelines:  Streptococcal pharyngitis: 10 days  AOM: If failed the watch and wait children >2 yrs; 5 days  Uncomplicated pneumonia: 7 days should due

19 Take care not to change or prolong antimicrobial therapy unnecessarily  Some infections can 3 days or more to defervesce; not equal to treatment failure  Cellulits can take over a day to improve on therapy and not a reason to progress to broader coverage.  Consider other diagnosis if no evidence of infection or response to antibiotics:  Kawasakis, neoplasms, juvenile inflammatory arthris, inflammatory bowel disease and recurrent fever syndrome s

20 Promote vaccinations !!!!!!!!!!!!!!!!!!!!!  Vaccines prevent infections…. Therefore less antibiotic use

21 Wrap up: 10 ways to promote antimicrobial stewardship in your paediatric practice 1. Mindful Reflection: Always document a childs vital signs and PE and why you are using antibiotics 2. Detail suspected drug reaction, does history meets true allergy criteria? Consider consultation with an allergist. 3. Ensure minimum diagnostic criteria be met for patients with suspected UTI. 4. Infections caused by GAS are best treated with beta-lactam antibiotics not azithromycin or macrolides. Use cloxacillin or cephalexin for Staphylococcus aureus 5. There is no need for throat cultures in children with colds & sore throat. A GAS+ culture almost always identifies a carrier and not a true infections

22 Wrap up: 10 ways to promote antimicrobial stewardship in your paediatric practice 6. ALWAYS use appropriate weight based dose & optimize frequency and duration. 7. Community acquired pneumonia in children is ampicillin IV or oral amoxicillin TID. 8. Prior to prescribing antibiotics for pneumonia a CXR should be obtained for diagnosis 9. Children with wheezing almost never require antibiotics; asthma in older children or bronchiolitis for infants. 10. Know the bacteria that cause the most common outpatient infections. Minor skin infections can be treated topically. Visble drainiage should be cultured. Managing Antimicrobial stewardship in daily practice:Managing an important resource CPS 2014

23 iPHONE to iCHEMO  July 2015: A review of cell phone exposure from and government documents on microwave radiation (MWR) levels and electronic device manufacturers manuals revealed that there ARE associations between MWR and the development of cancer in children  The researchers advocated  more wide spread implementation of MWR exposure limits on electronic devices,  better education about potential risks  BANNING MWR emitting toys or devices targeted at children Morgan et al. Journal of Microscopy and ultrastructure 2014

24  MWR exposure limits have remained unchanged for 19 years,  smartphone manufacturers specify the minimum distance from the body that their products must be kept so that legal limits for exposure to MWR are not exceeded.  For laptop computers and tablets, the minimum distance from the body is 20 cm  Phones are not tested in pants or shirt pockets.  Therefore every cellphone manual has warnings that the phone should be kept at various distances from the body  otherwise the human exposure limits can be exceeded.

25 iPhone on M’iBody The BlackBerry Torch 9800 Smart Phone  “keep the BlackBerry device at least 0.98 in. from your body (including the abdomen of pregnant women and the lower abdomen of teenagers).” The iPhone 5's manual  Users must go to “Settings,” and scroll down to “General,” then scroll to the bottom to “About,” go to “Legal,” scroll down to “RF [MWR] Exposure”  To reduce exposure to RF energy, use a hands-free option, such as the built-in speakerphone, the supplied headphones, or other similar accessories.  Carry iPhone at least 10 mm away from your body to ensure exposure levels remain at or below the as-tested [exposure limit] levels.”


27 conclusions 1. The risk to children and adolescent from exposure to microwave radiating devices is considerable. Adults have a smaller but very real risk, as well. 2. Children absorb greater amount of microwave radiation (MWR) than adults 3. MWR is a Class 2B (possible) carcinogen. 4. Fetuses are even more vulnerable than children. Therefore pregnant women should avoid exposing their fetus to microwave radiation.

28 conclusions 1. Adolescent girls and women should not place cellphones in their bras or in hijabs. 2. Cellphone manual warnings make clear an overexposure problem exists. 3. Wireless devices are radio transmitters, not toys. Selling toys that use them should be banned. 4. Government warnings have been issued but most of the public are unaware of such warnings. 5. Exposure limits are inadequate and should be revised such that they are adequate.

29 Cell phones, kids and cancer  Another recent study showed in individuals using a wireless phone for more than 25 years the risk for glioma TRIPLED (Hardell et al. Pathophysiology 2014)  Those who begun using a mobile or cordless device prior to 20y old were also at risk  Common sites for glioma were the temporal and overlapping lobes on the side the phone was placed  The International Agency for Research on Cancer classifies the electromagnetic fields produced by mobile phones as possibly carcinogenic. A formal risk assessment to be out in 2016

30 Should we panic? ?

31 Cell phone, kids and cancer  No definitive data available  Issues with some of the data, as many of the reports are anecdotal.  Public health data is unable to determine if there is one or many environmental concerns  Is the perceived increase is simply better recognition at earlier stages based on the availability of MRI? as well as better reporting?  At this time continue to use anticipatory guidance such as limiting screen time on MWR emitting devices  Limiting time on the phone and encouraging physical activity and social events  Reassuringly most teens text now and don’t speak to each other


33 PRAM SCOREs; preventing unneeded hospital stays  Tool developed in Calgary  Helps asses which children can be discharged  Less time in the ER/clinic  Also a modified score for children admitted to the ward  Will be rolling it out at UHNBC paediatric ward  Useful for our ED docs too

34 Emergent & Urgent Care Asthma Clinical Score (PRAM ) Signs0123 Suprasternal Indrawing AbsentPresent Scalene RetractionsAbsentPresent WheezingAbsentExpiratory only Inspiratory & expiratory Audible w/o steth or silent chest Air bases Widespread decrease Absent/minimal O2 sat on RA>93%90-93%<90% Severity ClassificationPRAM CLINICAL score MILD0-4 MODERATE5-8 SEVERE9-12 IMPENDING RESP FAILURE12+ following lethargy, cyanosis, decreasing resp effort, &/or rising CO2

35 For any child over 1 year of age and less than 17 Presenting with wheeze & respiratory distress Diagnosed with asthma 2 previous treatment with bronchodialator for asthma SEVERE 8-12 OR Impending resp failure MODERATE 4-7 MILD 0-3 Notify physician or NP Sabutamol q20min x3 + Ipratropium q 20min x 3 In the 1 st hr + Give steroids after 1 st MDI as per MD Salbutamol q20min 1-2 doses In 1 st hour 0-3 D/C Reassess PRAM q min 8-12 OR Impending resp failure

36 MODERAT E 4-7 Sabutamol q20min x3 + Ipratropium q 20min x 3 In the 1 st hr + Give steroids after 1 st MDI as per MD Reassess PRAM q min 4-7 Notify MD/NP Salbutamol q1h 0-3 Observe 1hr post last Beta2 agonist 0-3 Discharge medication/follow up Asthma education GP f/u 6hr post oral steroid If PRAM 0-3 YES ON NONO ADMIT

37 Inpatient Assessment Score (Modified PRAM) Signs0123 Suprasternal Indrawing absentPresent Scalene Retractions absentpresent WheezingabsentExpiration only Insp. & expiratory Audible or silent chest Air EntryNormalDecreased at bases Widespread decrease Absent minimal Phase Change Criteria: SCORE of <3 at routine assessment or MD order on reassessment in Phase I or Phase II For B2 agonist assessment: if SCORE >3 give B2 agonist if <3 no B2 agonist For any assessment SCORE >6 give B2 agonist and notify MD. If in Phase II or III move back to previous Phase. If in Phase one consider further investigations and reassess therapy (consider ICU, transfer, paediatric consultation)


39 Like a fat kid on candy  NEJM : obesity is increasing in the USA  BMI >95%tile children 6- 11y 4.2%  BMI >95%tile children 6- 11y 15.3%  How do we identify vulnerable ages?  How can we target resources to prevent obesity?  Environment? Genetics?  Poor choices? Media influence? Lack of exercise?  Age???????????????

40 Cute chubby baby  NEJM 2014 article looked at the incidence of childhood obesity in the United States:  Followed a cohort of 7738 kindergarteners to 8 th grade ( )  Weight and height were measured 7 times  Age, sex, and socioeconomic factors were collected

41 Socioeconomics  At kindergarten entrance age (~5.6yr) 14.9% were overweight and 12.4% were obese  The greatest increase in prevalence of obesity was between 1 st and 3 rd grade  In black and Hispanic children the prevalence of obesity was higher than in white children  Children from the wealthiest 20% of families had a lower prevalence of obesity:  7.4% vs 13.8% and 16.5% (the 2 poorest quintiles)  These differences increased through to the 8 th grade NEJM 2014

42 Incidence  AGA or SGA did not affect obesity rates  LGA (>4000g) had a higher prevalence  Although prevalence increased with age; the incidence declined  Kindergarteners : annual incidence 5.4%  Grade 5-8: annual incidence 1.9% boys 1.4 % girls  45.3% of incident obesity cases between kind and 8 th grade occurred from the 14.9% of children who were overweight when they started  The annual incidence of obesity in kindergarteners who were overweight was 19.7% compared with their normal weight peers  Overweight children from the 2 highest socioeconomic groups had 5x the risk of becoming obese as normal weight children in the same group NEJM 2014

43 Main Findings 1. Overweight children were 4 x as likely to become clinically obese 2. The annual incidence of obesity decreased from 5.4% in kindergarten to 1.7% between 5 th and 8 th grade 3. The time to act may have been missed by the time a child enters kindergarten is missed; when 12.4% are obese & an additional 14.9% overweight 4. Poverty is a risk factor NEJM 2014

44 Timing of adiposity rebound and adiposity in adolescence Pediatrics 2014 Hughes et al  Sample BMI of a cohort of children followed from birth at 3 periods of timing until 15 years of age.  Adipostiy Rebound: the period in childhood where BMI begins to increase from its nadir  Very early AR occurred <43 mon  Early AR later AR >61mo  BMI higher in adolescence with very early AR  was also higher for those with early AR compared with those with later AR (>5 years)  Children of obese parents had the greatest risk of early AR

45 Conclusion before 5 years of age  A component of the course to obesity is established before 5 years of age  Preventive interventions should consider targeting modifiable factors in early childhood to delay timing of AR.  The overweight children tend to become obese early in school  Interventions should target the whole family; not just the children  Should this be discussed at early childhood visits or during pregnancy?

46 Autism…. AVOID EVERYTHING  Last spring CDC calculated the prevalence of autism spectrum disorders in 2010 at 1/68 children aged 8 VS /88.  During this time there was no change in diagnostic criteria or data collection methods  Speculate that children may have been “missed” or “misdiagnosed” Dr. Hyman, Medscape  Not everyone believes the “missed” theory  There is a genetic link however the increasing incidence has spurred investigations into potential environmental triggers

47 As if pregnancy wasn’t hard enough  Links of autism risk to  Maternal intake of iron  Particulate air pollution  Preeclampsia  Pregnancy weight gain  Pesticides  And the list goes on  There is some interventions!

48 Maternal intake of Supplemental Iron and Risk of Autism Spectrum Disorder Schmidt et al Am J Epidemiol 2014  Iron is critical or early neurodevelopmental processes that are dysregulated in ASD  Iron deficiency affects 40-50% of pregnancies  Studied maternal iron intake in relation to ASD risk in California-born children  Iron intake studied from 3 months before pregnancy through to the end or pregnancy or breastfeeding

49 Maternal intake of Supplemental Iron and Risk of Autism Spectrum Disorder Schmidt et al Am J Epidemiol 2014  Mothers of cases were less likely to report taking iron-specific supplements vs controls  Mothers of cases had a lower mean daily iron intake vs controls  The highest quintile of iron intake during the index period was associated with a reduced ASD risk compared to the lowest  Most notable during breast feeding  Low iron combined with advanced maternal age and metabolic conditions; were associated with a 5 fold increase ASD risk

50 Autism Risk liked to Particulate Air Pollution Medscape Dec  Children whose mothers were exposed to high levels of fine particulate pollution late in pregnancy have a 2 x risk of developing autism vs breathing cleaner air Harvard school of Public Health  Ie. Fires, vehicles and industrial smokestacks  Greater exposure greater the risk  Previous research 2010: mothers living near highways during their 3 rd trimester. Autism risk doubled.

51 Autism Risk liked to Particulate Air Pollution Medscape Dec  Harvard study:  Nurses Health Study II began in 1989  Compared prenatal histories of 245 children with ASD to 1522 normal developing children  No association between fine particulate pollution exposure before or early in pregnancy or after the child was born  High levels of exposure during the 3 rd trimester DOUBLED the risk of autism  Not clear about how the contaminants disrupt brain development

52 Preeclampsia Linked to Autism, Developmental Delay. Medscape Dec  CHARGE study : compared 517 children with ASD, 194 with DD and 350 typically developing children.  Exposure to preeclampsia in utero associated with a greater than 5x vs no exposure for developmental delay and just over 2x for autism  Preeclampsia common in obese women or those who have diabetes or chronic hypertension  NB: over half of pregnant women in USA are overweight or obese  Interpret this study with caution; given the multiple factors at play and small numbers

53 Pregnancy Weight Gain May influence Autism Risk  In 2 separate cohorts from Utah Bilder et al Pediatrics found a positive association between prenatal weight gain; but not pregnancy weight and risk for ASD  ASD risk was significantly associated with pregnancy weight gain; in two separate groups with an odds ratio of 1.1 and 1.7 for each 5 pounds of weight gained  Note the absolute weight gain difference in the two case and control was only 3 lbs  OR very modest increase  I would not tell a mother to not gain weight due to this study

54 Pesticides and Autism Spectrum Disorders  CHARGE study again  486 children with ASD, 168 with delayed development and 316 controls  Assessed timing and extent of pesticides application 1.75km of the mothers residence from 3 mots before conception to time of delivery  Strong association between ASD  application of nonspecified organophosphate during 3 rd trimester  Chlorpyrifos during 2 nd trimester  Significant association between  ASD and pyrethroid application during both preconception and 3 rd trimester  Carbamate application and developmental delay (smaller number)

55 Pesticides and Autism Spectrum Disorders  Chlorpyrifos is banned for residential use  Often drift into other areas  Study is retrospective and no biological samples were collected  No account for pesticide use in the home or other exposures  Don’t lick the green green grass; especially when pregnant.

56  The study involved 54 families participating in the British Autism Study of Infant Siblings with at least one autistic child.  Studies suggest that about 20% of infants with an older sibling with an autism spectrum disorder (ASD) develop ASD themselves.  28 families were randomly assigned to a specially adapted Video Interaction for Promoting Positive Parenting Program (iBASIS-VIPP); 26 were randomly assigned to receive no intervention.

57 Video Program May Prevent Autism in High Risk Infants  Lancet psychiatry: Videotaped parent and child interactions in 1 st yr of life  The intervention group received at least six home-based visits from a therapist  video feedback to help parents understand and respond to their infant's style of communication  goal of improving infant attention, communication, early language development, and social engagement.

58  The high-risk infants were assessed at baseline when they were 7 to 10 months old and again 5 months after the intervention or after receiving no intervention.  After 5 months, infants in the intervention group showed improvements in several known ASD risk markers, including engagement, attention, and social behavior.  The infants also showed improved social behavior with people other than their parents.  Intervention infants showed a reduction in autism-risk behaviors, as assessed by the Autism Observation Scale for Infants (effect size 0.50; 95% CI, to 1.08), suggesting that video-based therapy may help modify the emergence of autistic behaviors during early development.  Offers the possibility of providing a focused low-intensity intervention on the basis of risk, without the need to identify a specific condition such as Autism Spectrum Disorder.“

59 Kids having babies… New guidelines from the AAP this year highlighted: 1. Trend of decreasing teen sexual activity and teen pregnancies since 1991 continues 2. Teen birth rates at a record low, owing to increased use of contraception at 1 st intercourse and use of dual methods of contraception in sexually active teens 3. United States still tops all other industrialized countries in terms of teen birth rates. 4. Less than one third of sexually active females (aged years) used contraceptive methods during their most recent engagement in intercourse.

60 A bit better in Canada  Even with increases in teen pregnancy in parts of Canada, the country still has a much lower rate than the United States.  In 2008 Canada’s rate was 30.5, while in the U.S. it was  Differences include: universal health care, access to contraception and sex education and the lower rate of poverty among young people.

61 Teen pregnancy: Who is at risk??  experiencing social and family difficulties;  whose mothers were adolescent mothers;  undergoing early puberty;  who have been sexually abused;  with frequent school absenteeism or lacking vocational goals;  with siblings who were pregnant during adolescence;  who use tobacco, alcohol and other substances; and  who live in group homes, detention centres or are street-involved. CPS: Adolescent Pregnancy reaffirmed Feb 2014

62  Health care practitioners have an important role in preventing unplanned adolescent pregnancies.  Include longitudinal follow-up of at risk teens, provision of a continuum of options from abstinence to contraceptive information  To discuss decision-making in a manner appropriate to the adolescent’s development.  Particularly important for adolescents with a developmental delay, disability or chronic condition.  Teens of both sexes who may engage in sexual activity should be counselled in methods of contraception.  Including information about the emergency contraceptive pill CPS: Adolescent Pregnancy reaffirmed Feb 2014

63 Contraception AAP 2014 statement 1. Counseling about abstinence and postponement of sexual intercourse is an import aspect of adolescent sexual health. 2. Long-acting reversible contraception should be considered first-line contraceptive choices for adolescents. 3. A pelvic exam is NOT required to prescribe contraceptives or refer for IUD placement. 4. Screening for sexually transmitted infections (STIs) can be performed without a pelvic examination and should not delay the initiation of contraception. 5. Encourage the correct and consistent use of condoms "each time, every time" and should take the opportunity to pair this encouragement with a regular update of their patients' sexual histories in a confidential and nonjudgmental setting.

64 CPS 2014  counsel pregnant adolescents in a nonjudgmental way about their pregnancy options.  If they are unable to do so, they should refer to others who can provide this service;  attempt to protect adolescents from being coerced into any option against their will;  help the adolescent develop a supportive network that may include family members, her partner, trusted friends and other health care providers;  provide people in that support network with guidance as to how they can best help the pregnant adolescent;  make follow-up appointments;  ensure that adolescents referred to another practitioner or service have made and kept their appointment; and  respect the adolescent’s right to privacy and medical confidentiality.

65 7 th heaven  CATT in concussions  Return to play  Return to learn

66 PS… remember the RACELINE

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