ࡱ> 8:/01234567<Fww#` bjbj Y    4;;;hl;(= @LHI U(UUUD>$$hZ bJ\bb UU *b, @U Ub OpT6  U 37.5 degrees C. Replacement Fluid (Deficit = existing + ongoing losses) Ongoing losses, e.g., due to significant diarrhoea or vomiting, may be replaced intravenously on an ml-for-ml basis or as part-replacement if the patient is also tolerating some oral fluids. Existing losses (i.e., dehydration) Percentage dehydration can be estimated clinically using the following parameters: (APLS guidelines) Signs and Symptoms of Dehydration Sign/Symptom Mild Moderate Severe (<5%) (5-10%) >10% Decreased urine output + + + Dry mouth +/- + + Decreased skin turgor - +/- + Tachypnoea - +/- + Tachycardia - +/- + NB Tachypnoea may be due to, or worsened by, metabolic acidosis & pyrexia. Tachycardia may be due to hypovolaemia, but also due to other causes e.g. pyrexia, pain or irritability. A low blood pressure is a serious sign in a child: it may be due to hydration / hypovolaemia or due to other causes e.g. septic shock. It is a late/peri-arrest sign, and preventative action should be taken prior to the child reaching this stage. To Calculate Replacement Fluids (according to % dehydration): Fluid deficit (ml) = Percentage dehydration x Weight (kg) x 10 e.g., A 24 kg child is 7.5% dehydrated, calculated fluid requirement. (Assuming no resuscitation required) Fluid deficit = 7.5 x 24 x 10 = 1800ml Maintenance = (100 x 10kg) + (50 x 10kg) + (20 x 5kg) = 1000 + 500 + 80 = 1580ml Thus Total fluid requirement = Maintenance + Deficit + Resuscitation fluids = 1580ml + 1800ml + 0 = 3380ml over 24 hours (+ addition for ongoing losses on a ml-for-ml basis) Normal Daily Electrolyte Requirements Sodium 2-4mmol/kg/day Potassium 2 mmol/kg/day Calcium 3 mmol/kg/day Magnesium 0.75mmol/kg/day To calculate electrolyte deficit: Deficit (mmol) = (Normal level actual level) x weight (in kg) x 0.7 e.g., 24kg child with serum potassium of 2.5mmol/l Deficit = (4-2.5) x 24 x 0.7 = 25.2mmol Maintenance = 2mmol/kg/day = 2 x 24 = 48mmol Thus, total requirement = Deficit + Maintenance = 25 + 48 = 73mmol If not taking oral fluids will need maintenance hydration containing 73mmol over next 24 hours. If taking diet, and hence maintenance electrolytes, needs 25 mmol extra potassium over next 24 hours. GASTRO-OESOPHAGEAL REFLUX GOR is a very common and probably under recognised problem in neurologically impaired children, perhaps around 50% (15-75%) in this group. The commonest GOR-associated symptoms are shown in bold type. The symptoms are particularly significant if multiple, and if during or after feeds. Gastro-intestinal: Food refusal Vomiting (especially during /after feeds and supine at night) Dysphagia / difficulty swallowing Weight loss / failure to thrive Haematemesis / melaena Respiratory: Troublesome secretions Aspiration pneumonia Recurrent RTIs / bronchitis Cough Wheezing Choking / gagging Other symptoms, especially with temporal relation to feeding: Irritability (especially when supine) Pain Hyperextensive posturing Sandifers syndrome (neck extension and head rotation during / after meals in infant / young child, associated with iron deficiency anaemia and severe oesophagitis) Non-drug treatments Adjust posture. Alter feeding regime from large bolus to frequent small volume, or if nasogastric/gastrostomy fed, overnight feeding / continuous feeding (sometime this may aggravate symptoms: try it and see). Check for overfeeding, especially if nasogastric/gastrostomy fed. Thicken feed with gum or starch. However, this may aggravate symptoms by osmotic effect. Drug treatments Antacids, especially Gaviscon for its raft as well as antacid effects Omeprazole reduces noxious effects of reflux via its actions as a proton pump inhibitor. Ranitidine can be used as second line, but can give problems with rebound nocturnal acid secretion. Prokinetic e.g. domperidone or metoclopramide. If, despite maximal medical therapy, vomiting, weight loss or distress continues then surgery needs to be considered. Fundoplication with or without pyloroplasty is effective in over 80% of cases, but has a high morbidity (26-59% post-operative complications, 6-70% get recurrent GOR and 5-15% need repeat surgery). If the child has severely compromised nutrition, inefficient feeding, NGT dependency or swallowing problems then gastrostomy should be considered simultaneously. Table 11: Drugs used to treat gastro-oesophageal reflux DRUGROUTETOTAL DAILY DOSE (T.D.D.)TIMES DAILY (Divide T.D.D. by this figure)1 month to 12 yearsOver 12 yearsGavisconOral liquidOver 2 years 5-10mls10-20mlSingle dose after mealsInfant sachet 1 dose = half a dual sachetUnder 2 years < 4.5 kg = 1 dose > 4.5kg = 2 dosesSingle dose with each feedOmeprazoleOral700 microgram/kg up to 3mg/kg/day20-40mgOnceRanitidineOral4-8mg/kg (maximum 300mg)TwiceDomperidone Oral200-400mcg/kg (Up to 1.6mg/kg/24hrs)10-20mgSingle dose (May be repeated up to 4 times. Watch for extrapyramidal effects)MetoclopramideOral200-300mcg/kgUnder 60kg 15mg Over 60kg 30mgThree Omeprazole For children who can not swallow tablets or capsules then the following can be tried Open capsule and mix granules with acidic drink (orange or apple juice) and swallow without chewing MUPS tablets can be dispersed in water, fruit juice or yogurt For PEG and NG tubes the MUPS tablets can be dispersed in a large volume of water For PEG and NG tubes the granules can be mixed with 10mL of sodium bicarbonate 8.4% and left to stand for 10 minutes until a turbid suspension is formed. The suspension is given immediately then flushed with water For older children Lansoprazole fastabs dissolve very well in water and do not block the tubes as badly as omeprazole. GASTROSTOMY CARE Many of the children requiring palliative care will have a gastrostomy in situ, often for feeding requirements or for medication to be administered where the oral route is either inappropriate or holds the potential risk of aspiration/choking for the child. The two main types of gastrostomy tubes are PEG ( Percutaneous Endoscopic Gastrostomy ) and balloon type , usually a MICKEY. There are various reasons why some children have one type and some have another. Such reasons could be the length of time the device is in situ, the surgeons preference and the appropriateness of the device for the child and family.   PEG tube MIC-KEY Button DAILY CARE Clean the skin around the stoma site and under the external fixation device or Mickey head with warm water daily. Normal bath or shower routine can be followed, but the new stoma site should not be submerged in water for 3 weeks post-operatively. Ensure area thoroughly dried. Do not use talcum powder around stoma area. To prevent blockage, the gastrostomy tube should be flushed with water before and after all feeds and medication. Usually a minimum of 10mls of water unless the child is fluid restricted or a small infant. Rotate gastrostomy tube 360 degrees every day to help avoid the formation of granulation tissue. Check any external fixation device, (present on all PEGs & some balloon tubes), is comfortably positioned approximately 2mm from the skin surface, and adjust according to manufacturers instructions. THE RETENTION DEVICE SHOULD NOT BE MOVED FOR TWO WEEKS POST OPERATIVELY , TO ALLOW TRACT TO BECOME ESTABLISHED. IF TIGHTNESS OR DISCOMFORT IS NOTED DURING THIS TIME, CONTACT APPROPRIATE MEDICAL STAFF. Avoid the use of occlusive dressings over the gastrostomy as these may encourage skin maceration and bacterial growth. Check stoma site for signs of irritation, redness or swelling. Contact appropriate medical / nursing staff for advice. ORAL HYGIENE If a child has reduced or no oral feeds, plaque can build up on their teeth rapidly. Poor oral hygiene will cause soreness and pain. Teeth need to be cleaned twice daily, and artificial saliva or mouthwash can be used where appropriate. WEEKLY CARE OF BALLOON GASTROSTOMY If gastrostomy is newly formed, do not deflate the balloon until 2 WEEKS post-operatively to ensure stomach firmly adhered to the abdominal wall. Once established, change water in balloon weekly using sterile water if in hospital, or cooled boiled water in the home. (Usually 5mls). A balloon gastrostomy will require replacing every 4 6 months according to the manufacturers instructions. TUBE BLOCKAGE It is important that the gastrostomy tube is only used for administering specific enteral feed, water or medication in an appropriate form i.e. liquid, unless specified by a pharmacist. In the event of a blockage the following tactics can be tried:- Using a 50ml syringe the following fluid (25-30mls) can be used (as age appropriate) to try to unblock the tube, usually a minimum of 10mls. Flush with warm water. Flush with soda water. Flush with cola. Flush with pineapple juice (contains an enzyme that helps to dissolve the blockage). If blockage persists, gently draw back on the syringe and flush as before. Gently squeeze the tube between your fingers along its length to milk the tubing. If blockage persists:- PEG - a pancreatic enzyme ( Pancrex V ) may be obtained from a dietitian / doctor which is instilled and left in the tube for approximately 30 minutes , then retry the above. If remains blocked, contact appropriate medical staff. MicKey / Balloon gastrostomy - consider a change of tube by an appropriately trained individual deemed competent to do so. LEAKAGE AROUND THE STOMA SITE A newly formed gastrostomy may experience slight seepage around tube until the tract is established. If established balloon gastrostomy, check sufficient water in balloon. If established PEG, check external fixation device has not slipped by pulling gently on gastrostomy tube until resistance is met and positioning fixation device 2mm from skin surface. Aspirate tube prior to feeding to remove excessive air from stomach:- PEG - use 50ml syringe ensuring Luer port is closed. MICKEY - as above or use decompression tube provided with the kit. If child inactive, encourage sitting upright following feed or position on right side with head elevated, to promote gastric emptying. Discuss with Dietitian the possibility of reducing rate of feed, or giving smaller, more frequent feeds. Gastric contents will quickly cause excoriation and soreness. Protect the skin with water proofing product such as stoma care skin wipes or Cavilon, whilst establishing and correcting cause. If leakage persists, contact appropriate medical staff. Ensure leakage not due to:- 1. Granulation tissue. Looks like a raised red lip or cauliflower type growth(s) around the stoma site. Will produce a copious, sticky, mucus type discharge - often mistaken for infection. Treatment = Topical steroid based, antifungal cream i.e. TriAdcortyl. Apply twice daily for maximum of 10 days then review. May need 2nd course of treatment but advise parent / carer against prolonged use. If in doubt swab before starting treatment. 2. Infection. Inspect for signs of redness, swelling or tenderness around gastrostomy site. Note colour and consistency of leakage. If infection suspected swab before starting treatment. Consider Fucidin cream for topical application or systemic antibiotics. (Caution with erythromycin with children who have epilepsy). IF GASTROSTOMY TUBE PULLED OUT Appropriate action needs to be taken as soon as possible as the stoma will begin to close after 4 6 hours. Leakage may occur from the stoma site use skin protective wipe or Cavilon if available, and cover with dry dressing. Mickey or balloon gastrostomy. Child should have spare tube with them which can be replaced by appropriately trained nursing / medical staff or carers. Or contact hospital ward or Childrens Community Nurses. PEG gastrostomy. Contact hospital surgical team as soon as possible. A size 12g Foley catheter can be used to keep the stoma patent until PEG is replaced. If this is to be used for feeds / medication - ensure tip of catheter has not migrated into small bowel inflate balloon and pull back gently until resistance felt, secure to skin with tape, note length of external catheter from stoma site. HICCOUGHS Hiccough is a common occurrence in normal individuals, and only becomes a symptom when it becomes troublesome, severe or intractable, which can occur in palliative care situations. In terminal care the most common cause of hiccough is gastric distension. The first line of treatment is often a defoaming antiflatulent containing Simeticone (active dimeticone such as Asilone or Maalox Plus). If this fails to settle the hiccough a prokinetic drug such as Metoclopramide can be added to tighten the lower oesophageal sphincter and promote gastric emptying. Sometimes peppermint water is helpful, by relaxing the lower oesophageal sphincter to facilitate belching, but as this works in opposition to the action of Metoclopramide these two should not be given together. Gastrointestinal reflux can sometimes cause hiccough, and this can be reduced by the use of prokinetics such as Metoclopramide, or by H2 antagonists or proton pump inhibitors. Diaphragmatic irritation is another cause of hiccough seen in palliative care. Baclofen is seen as the drug of choice with its muscle relaxant properties. There are also single case reports in adults for the use of Gabapentin, Nifedipine and Haloperidol supporting their potential benefit for intractable hiccough. Stimulation of the pharynx may help with the management of hiccough, and this is the basis for how a lot of the traditional folk remedies for hiccough may work. Such advice includes swallowing crushed ice, a cold key down the back of the neck, and drinking from the wrong side of the cup. More medically based treatments that stimulate the pharynx include normal saline 2mls nebulized over 5 minutes, and oro-pharyngeal stimulation with an NG tube, both of which suggested a reduction in hiccough. A similar method is by massaging the junction between the hard and soft palate with a cotton bud. Forced traction of the tongue to stimulate a gag reflex is also thought to potentially work by pharyngeal stimulation. Central suppression of the hiccough reflux can be achieved in several ways. Re-breathing air out of a paper bag and breath holding are both thought to inhibit processing of the hiccough reflex in the brain stem by elevating PaCO2 Dopamine antagonists such as Metoclopramide may help by both their central action and if there is associated gastric distension. Other drugs to centrally suppress hiccough include Haloperidol, or Chlorpromazine. GABA agonists such as Sodium Valproate 200 to 500mg daily are also potentially effective by central suppression. Potential biochemical causes of hiccough should be sought and corrected appropriately if possible, including hyponatraemia, hypocalcaemia (e.g. after bisphosphonate treatment), and in renal failure. If hiccoughs persist, the possibility of infection or a brain stem lesion / intra-cranial lesion should be considered. In summary, if hiccoughs become a persistent and distressing symptom, effort should be made to relieve treatable causes such as gastric distension and reflux or correct biochemical causes, whilst considering infection and neurological causes. Simple folk remedies and attempts at other methods of pharyngeal stimulation should then be tried, followed by specific drug treatment if the above remedies have proved ineffective. Table 12: Drugs used to treat hiccoughs DRUGROUTETOTAL DAILY DOSE (T.D.D.)TIMES DAILY (Divide T.D.D. by this figure)1 month to 12 yearsOver 12 yearsOmeprazoleOral700 microgram/kg up to 3mg/kg/day20-40mgOnceAsiloneOral5-10mlsAfter meals and bedtimeMaalox PlusOralUnder 5 years 5mlsOver 5 years 5-10mlsAfter meals and bedtimeHaloperidolOral4.5mgThree Start with lower dose and increase as requiredChlorpromazineOralOver 6 years 10-30mgOne to Three100-200mgThree to FourMetoclopramideOral200-300 micrograms/kgUnder 60kg 15mg Over 60kg 30mgThree INFECTIONS Any infection causing symptoms and affecting quality of life should be treated. Antibiotic resistance and allergies are a common problem. In the palliative care setting rules may be bent; hence antibiotics not normally recommended for children e.g. tetracycline could be given. Other antibiotics not normally available in liquid form for children can be given. Hospital pharmacies and traditional retail pharmacies can be very helpful in providing such information. Remember to record in the notes and discuss with the parents what you are doing to protect yourselves medico-legally. Pneumonia is sometimes called the old mans friend. It is also the commonest cause of the terminal event in many children with life threatening conditions. The use of antibiotics can present the parents and care team with an ethical dilemma. It is best to sit down and discuss the pros and cons of treatment together. Oral treatment in the terminal phase does not extend the life expectancy of the child but can allow the parents to feel that they tried their best to the last. Most parents will accept that intravenous antibiotics are normally inappropriate at this stage. It is worth remembering that while we cannot insist on treating an infection if the parents refuse, neither are we forced to give treatment that we consider is inappropriate. This type of dilemma is best resolved by negotiation with parents and, where appropriate, the child. Sometimes antibiotics are necessary e.g. pain relief in acute ear infections or severe tonsillitis, even when the parents of the child have decided on no more active treatment. MOUTHCARE This is an overlooked aspect of palliative care but correct management can easily enhance the quality of life for a dying child. As in all cases take a good history and look inside the mouth. Establishing the cause of the mouth problem helps to direct the correct treatment. Causes Oral candidiasis Poor oral hygiene Dry mouth from a) Mouth breathing b) Oxygen that has not been humidified c) Drugs i.e. morphine, hyoscine or amitriptyline d) Radiotherapy Mouth ulcer a) Traumatic b) Aphthous Bleeding gums from a) Haematological cancers b) Liver disease c) Clotting disorders Oral hygiene can be maintained by careful and gentle cleaning of teeth and gums. This is a task that the parents may like to carry out as part of the childs daily routine. Pink sponges dipped in mouthwash can be applied to the gums and teeth to keep the mouth moist and cream applied to the lips to prevent dryness and cracking. This attention to mouth care will go a long way to maintaining hygiene, preventing some of the complications and aiding the childs comfort. Oral thrush can be cleared using various anti-fungal agents. Nystatin drops are really not very effective in these cases and miconazole oral gel applied gently around the mouth is better. Fluconazole, which is a once daily oral anti-candidal agent, is often more effective than topical agents. Artificial saliva e.g. Glandosane comes in various forms and the spray is particularly effective. KY Jelly is very effective for dry mouths and is well tolerated. Community dentists can advise regarding traumatic ulcers. Aphthous ulcers can be treated with Adcortyl in Orabase applied locally. Bleeding gums can be helped with tranexamic acid mouthwashes or haemostatic agents such as Gelfoam or Gelfilm. Bleeding from blood malignancies may require platelet transfusions even in the palliative setting. Oral ethamsylate decreases capillary bleeding and has been used in adults at a dose of 500mg qds in a palliative care setting. Table 13: Drugs used to treat mouth problems DRUGROUTETOTAL DAILY DOSE (T.D.D.)TIMES DAILY (Divide T.D.D. by this figure)1 month to 12 yearsOver 12 yearsMiconazole oral gel OralUnder 2 years 5ml22-6 years 10ml2Over 6 years 20ml4Tranexamic AcidOral75mg/kg2-6g3FluconazoleOralOver 4 weeks 3mg/kg50-100mg1 MUSCLE SPASM. Muscle spasm is a common problem in the neurodegenerative disorders. They may be due to pain: look for other clues to this, such as response to handling. Alternatively they may be epileptic tonic spasms. There is sometimes no substitute for sitting down, listening to the story carefully and watching the spasms. Anyone who has had muscle cramps will appreciate the level of pain that can be experienced. Children who have repeated muscle spasms are often very distressed. The early involvement of a physiotherapist may be useful and advice on seating, positioning, moving and handling may assist in preventing positioning that can cause muscle spasm. Unfortunately the treatment for the spasms can have some detrimental side effects. Increased muscle tone and spasm may be the only thing that allows the child to sit or stand up. Thus treatment may decrease the childs mobility. The medications can also cause unnecessary sedation. The two drugs worth trying are baclofen and diazepam. Baclofen may make epilepsy worse. Diazepam may be sedating and/or dulling. Dantrolene and tizanidine, although not licensed for children are both useful. A phone call to the local paediatric neurologist can be very helpful in difficult cases. Table 14: Drugs used to treat muscle spasm DRUGROUTETOTAL DAILY DOSE (T.D.D.)TIMES DAILY (Divide T.D.D. by this figure)1 month to 12 yearsOver 12 yearsBaclofenOral1-2 years 10-20mg100mg maximum3-42-6 years 20-30mg6-10years 30-60mgDiazepam Oral1 month-1 yr. 500mcg/kg 1-4 years 5mg 5-12 years 10mg6-30mg2-3DantroleneOral1mg/kg 2 (Initial dose)25mg1 (Initial dose)12mg/kg (Maximum 400mg)400mg4 (maximum dose) NAUSEA AND VOMITING The management of nausea and vomiting highlights the importance of understanding the cause of a symptom to determine the appropriate therapeutic course.  SHAPE \* MERGEFORMAT  Whilst nausea and vomiting can be effectively managed with medication, common sense principles must not be forgotten. Identify and manage the correctable causes e.g. pain, infection, drugs, biochemical, etc Certain smells may antagonise the nausea. Left over food must be removed immediately. Staff and parents advised against the use of strong perfumes. Strong odours avoided. Meals kept small but often, if the childs appetite allows. Once we have an understanding of the cause we can then target anti-emetics according to their mode of action. It may be necessary to use a number of different anti-emetics and logic dictates that we use medications from different groups. Many of the drugs used will overlap in their site of action. There is no evidence to support any particular dosage of dexamethasone when used as an anti-emetic. Another rule of thumb is 8mg/m2/day. Remember not for long-term use because of side effects and altered body image. Octreotide has been used in adults for vomiting secondary to obstruction but its benefits in children is unknown. If you need to use more than one anti-emetic then make sure they are complementary e.g. cyclizine and haloperidol and not antagonist e.g. cyclizine and domperidone. Table 15: Site of action of anti-emetic drugs DRUGSITE OF ACTIONNOTESHaloperidolChemoreceptor trigger zoneAnxiolytic benefitsThioridazineChemoreceptor trigger zoneMay have some benefits in epilepsy, although generally phenothiazine can exacerbate epilepsyChlorpromazineChemoreceptor trigger zoneSedation benefits. Contra-indicated in epilepsyProchlorperazineVestibular centre and Chemoreceptor trigger zoneSide effects in children limit useOndansetronChemoreceptor trigger zone Medulla Oblongata Also may work at vagal levelSide effects of flushing, headaches and constipation More effective combined with corticosteroids (dexamethasone) Onset of action 30mins, peak 1-2hrs, duration 12hrsCyclizineMedulla OblongataCommonly used and highly effective Sedating antihistamine with antimuscarinic properties May crystallise with diamorphine in s/c infusion Side effects drowsiness, dry mouth, blurred vision, urinary retention Onset 30mins, peak 2hrs, duration 4-6hrsLevomepromazineEffects at all levelsPhenothiazine Broad spectrum Use when there is failure of specific anti-emetic Stable with diamorphine in s/c infusion Side effects sedative and postural hypotensionDomperidoneVagal sympatheticProkinetic in upper gut Good for dysmotility in neurological conditionsMetoclopramideVagal sympatheticCrosses blood brain barrier Causes extrapyramidal side effects in children limit useDexamethasoneIntracranial pressureUse in short bursts due to side effects Reduces permeability of chemoreceptor trigger zone and blood brain barrier to emetogenic substances and reduce GABA in brainstem Table 16: Drugs used to treat nausea and vomiting DRUGROUTETOTAL DAILY DOSE (T.D.D.)TIMES DAILY (Divide T.D.D. by this figure)1 month to 12 yearsOver 12 yearsHaloperidolOral1-4mg2-3SC infusion25-50 mcg/kg/24hrsContinuousChlorpromazineOral2-5years 1.5mg/kg75-150mg36-12 years 30mgCyclizineOral5-12 years 75mg150mg3SC infusion1month-1yr 1mg/kg/24hrs50-100mgContinuous1-4 years 25mg5-12 years 50-100mgDomperidone Oral200-400mcg/kg (up to 1.6mg/kg/24hrs)10-20mgSingle doseRectal0ver 2 years 15-30mg30-60mgSingle dose Dexamethasone 2mg/5ml Oral1-6mg 2Levomepromazine Oral 1-18 yrs 0.25-1mg/kg 3-6 times/daySC infusion1-18 yrs 0.5-3mg/kg/dayMetoclopramideOral300mcg/kgUnder 60kg 15mg Over 60kg 30mg3OctreotideSC infusion25 micrograms/kg/24hrsContinuousThioridazine 25mg/5mlOral0.5-1.3mg/kg1-2.5mg/kg2OndansetronOralUnder 0.3m2 1mg8mgSingle dose every 8-12hrs0.3-0.6m2 2mg0.6-1.2m2 4mg0ver 1.2m2 8mg NEONATAL PALLIATIVE CARE Introduction There have been many advances both in antenatal diagnosis and neonatal intensive care over recent times. However there still remain a number of babies where full intensive care is not indicated, or is futile. There are a number of common reasons that neonatal intensive care may be withheld or withdrawn after discussion with the family including: Genetic problems with a limited life expectancy- for example Trisomy 18. Severe congenital abnormalities- for example spina bifida or cardiac problems that are not amenable to surgery. Complications of extreme prematurity- for example, low blood pressure that fails to respond to inotropic medication, or extensive bowel damage that is incompatible with life following necrotizing enterocolitis. Perinatal hypoxic brain injury with a poor prognosis. Some babies, particularly preterm babies, will already be receiving intensive care support when the decision is made to withdraw or withhold intensive care. The intensive care support received may include: Support of the respiratory system, either via an endotracheal tube, or via nasal continuous positive airway pressure (CPAP). Support of the blood pressure with inotropic medication. Infusion of opiate medications or muscle relaxants to facilitate artificial ventilation. Organ support (renal replacement therapy etc). Following discussion with the family, there may be a decision made, not to escalate the intensive care support further, or more commonly, to withdraw support, keep the baby comfortable and allow the baby to die with their family. Many parents will have built up a relationship with the team on the neonatal unit, and will choose to spend time with their baby on the intensive care unit, supported by the staff that they know. Some families may prefer for the baby to die at home, or in the hospice setting. It is usual practice on the intensive care unit to discontinue muscle relaxant medications, and allow these to wear off, but to continue any other sedative or analgesic medications after removing the baby from the ventilator. Intravenous access is often left in place to allow for the administration of palliative medications, but oral and subcutaneous medications can be given, even to the smallest of infants. There are a number of issues that need to be thought about when caring for the dying baby, and the principles of care are similar to those for an older child. It is important to remember that simple comfort measures, such as positioning the baby with suitable boundaries, gentle rocking and swaddling, can be very effective. Feeds Most full term babies will feed around 120ml per kilogram per day of breast or formula milk if left to their own devices. Most babies feed 6-7 times per day, but many breast fed infants feed more frequently than this. Preterm babies start to learn to suck and swallow at around 33-34 weeks gestation, and babies younger than this are usually fed via a nasogastric tube. Babies who are receiving palliative care should be allowed to feed orally if they wish to do so. They are likely to find breast feeding comforting even if they are not able to take much milk. If a baby is unable to take oral feeds, it is usually appropriate to offer feeds via a nasogastric tube. Providing around 50ml/kg/day of milk, split into 6-8 feeds, will keep the baby hydrated, and may produce less vomiting and feed intolerance than using higher volumes. The aim of this approach is to reduce distress from hunger, rather than to provide calories for growth. Gastro-oesophageal reflux A small amount of vomiting or posseting following feeds is normal for babies. Antiemetics are not often required or used in small babies because of the significant side effect profile. Gastro-oesophageal reflux is fairly common, particularly in babies with neurological problems. This can be distressing for the infant and can be dealt with by: Feeding with the head of the cot slightly elevated, and the baby lying with the left side down. Giving nasogastric feeds slowly (sometimes it is best to remove the plunger from the syringe and allow the milk to flow in by gravity.). Giving smaller volume feeds more regularly (2 hourly instead of 4 hourly for instance). Considering anti-reflux medications: Table 17: Drugs commonly used as anti-reflux medications in neonates: DrugUseDose Gaviscon Infant feed thickener/ alginate Half a dual sachet mixed with feeds (100ml of milk). If breast fed mix with a little water and give after the feed Ranitidine oral solution  H2 antagonist 1-2mg/kg up to three times daily Domperidone  prokinetic 100-300 microgram/kg four to six times daily before feeds Constipation Constipation can be a problem, particularly for babies taking long term opioids. Lactulose syrup 2.5ml twice daily titrated to response can be helpful, and ensuring adequate hydration is important. Lactulose may take 36-48 hours to act. Distressing constipation in babies can be relieved by administering the tip of a glycerine suppository rectally (it is easiest to slice a small chip off a 1 gram suppository with a blade) Pain It is imperative that all babies receiving palliative care have close attention paid to their analgesia. The assessment of pain in babies is very difficult. There are many pain scoring systems that have been widely used for neonates, but the scores given are often subjective and not always clinically useful. The following features are the most reliable indicators of pain in small babies: Persistent crying (although remember that a silent baby may be suffering from severe pain). Furrowing or bulging of the brow. Furrowing of the nasolabial folds (the folds between the lips and nose). Tight squeezing of the eyes. Simple environmental methods may be very effective for relieving pain in babies Babies (particularly preterm babies) will often settle simply with a dark, quiet, warm environment. Other methods include swaddling of the baby in a blanket, allowing the baby to suck at the breast or on a dummy (see below), gentle rocking, stroking and massage of the baby. There is good evidence that sucking on a syringe or dummy containing glucose or sucrose provides short term pain relief. This is particularly useful for procedural pain, including dressing/ stoma changes for example. Glucose 30% solution 1ml orally as required can be used. Non-opioid analgesia: Paracetamol: Paracetamol can be given orally, or PR if needed by cutting up suppositories. Paracetamol suspension, orally, 20mg/kg as a loading dose followed by 10-15mg every 6-8 hours (max 60mg/kg/day). Paracetamol suppository, rectally, 30mg/kg as a loading dose then 20mg/kg every 8 hours (maximum 60mg/kg/day). Non steroidal anti-inflammatory drugs: Ibuprofen suspension 5mg/kg 3-4 times per day, after feeds. Diclofenac is not usually recommended below 6 months of age because of the significant side effects. However, if the oral route is unavailable, rectal diclofenac may be useful in neonates weighing 3.125kg or greater. The dose is 0.3-1mg/kg tds. The smallest dose that can practically be given is 3.125mg (by cutting a 12.5mg suppository into quarters). Opioids Morphine remains the most commonly used medication for neonatal analgesia. Morphine can be given intravenously for acute pain, using a dose of 40 to 100 micrograms per kg as needed. Intravenous morphine infusions are used, even in the smallest preterm infants, and doses of 10-40 micrograms/kg/hour are often used. In unventilated babies the initial dose is 10-20 micrograms/kg/hour and is then titrated to response. High doses of morphine can lead to a change in the respiratory pattern, and occasionally respiratory depression. Subcutaneous infusions of morphine can be used in small babies, but are often problematic in small preterm infants, because of a lack of subcutaneous tissue. Diamorphine is useful for subcutaneous use as it is more water soluble than morphine so smaller infusion volumes can be achieved, and is the preferred opioid for subcutaneous use. Intravenous diamorphine has been extensively used in ventilated neonates, a dose of 100 micrograms/kg is useful for acute pain, and an initial infusion of 2.5 to 7 micrograms / kg / hour can be used safely in non-ventilated babies and then titrated to response. Morphine sulphate oral solution is the most common oral opioid used. The total daily intravenous opioid requirements can be calculated and converted to an oral regime, giving the morphine every 4 hours initially. Breakthrough analgesia (PRN doses) should also be prescribed and given in-between the regular doses if required. The dose is then adjusted to response - there is no maximum dose of morphine for neonatal palliative care- high doses of morphine will often change the breathing pattern, and may cause respiratory suppression. Codeine phosphate is occasionally used. It is not as effective as oral morphine and often causes problematic constipation. Opioids may also help to relieve breathlessness at rest. Fentanyl has been associated with chest wall muscle spasm in neonates, and is not often used. It is difficult to cut fentanyl patches into small enough pieces for use with small babies. Table 18: Drugs used to treat pain in neonates DrugDoseComments Morphine IV Morphine Subcutaneous Morphine Sulphate Orally 40 to 100 micrograms/kg 10-20 microgram/kg/hour continuous infusion 150 microgram/kg for acute pain Double the total daily IV morphine requirements can be titrated and given 4 hourly For acute pain- can be repeated as needed Usual starting dose for infusions in non ventilated babies- can be titrated according to response Diamorphine is preferable for using subcutaneously (see text) Morphine requirements are very variable- see text Diamorphine IV Diamorphine Subcutaneous 100 microgram/kg 2.5-7 microgram/kg/ hour Total daily oral morphine dose : subcutaneous diamorphine dose = 1:0.33 For acute pain Continuous infusion in non ventilated babies- can be adjusted to response See text Seizures Seizures are a common problem encountered in neonatal palliative care. These are often secondary to a perinatal hypoxic insult to the brain or a primary brain problem and can be distressing for the family to see. Seizures can manifest in subtle ways in babies, common features are cycling movements of the arms and legs, unusual mouth movements or lip smacking. There are a number of medications used for seizures in neonates- most neonatologists start with phenobarbital. Table19: Drugs used to treat seizures in neonates DrugDoseComments Phenobarbital (phenobarbitone)  Initially 10-20mg/kg loading dose often followed by a maintenance dose of 2.5-5mg/kg once daily Most commonly used first line medication in neonates- causes sedation and may suppress respiration in high doses Can be given iv or orally Phenytoin  Initially 20mg/kg loading followed by 2.5-5mg/kg twice daily Commonly used as a second line agent in neonates- can be given iv or orally. May cause blood and skin disorders with long term use Clonazepam For status epilepticus: 100 microgram/kg IV single dose- repeated after 24 hours if needed Very effective anticonvulsant- significant sedation which can be useful in palliative care. Can be given orally or iv- iv dose associated with respiratory depression Can be used to ameliorate distressing gasping Midazolam Seizures 300 microgram/kg buccal single dose 150 microgram/kg IV loading dose followed by 1 microgram /kg/minute IV infusion to control seizures if needed. Dose can be increased by 1microgram/kg/min every 15 minutes until seizure controlled (max dose 5 microgram /kg/min) For sedation a dose of 50-100microgram/ kg IV or subcut can be used Midazolam is not often used for iv or subcut infusions in neonates as it tends to accumulate, and can cause respiratory depression. It is not licensed for sedation below 6 months but is still occasionally used, with good effect Can be used to ameliorate distressing gasping Sedation It is important to ensure that babies who are unsettled are not in pain. Occasionally babies benefit from oral sedative drugs to help them sleep. The most commonly used sedatives in babies are: Chloral hydrate 30-50mg/kg orally or rectally at night / as required. May be used up to QDS for continuing sedation. The oral solution can be given rectally if suitably sized suppositories are unavailable. (Chloral can accumulate if used regularly in babies. It is also irritant to the stomach if given orally so should ideally be given with or after milk feeds). Alimemazine (trimeprazine) 2-4mg/kg orally as required (max four times daily). Excessive Secretions Many babies with neurological problems have difficulties clearing secretions from their mouth and pharynx. Some babies are managed at home, or in the hospice setting with oral suction. Hyoscine patches (quarter of a patch, applied behind the ear, every 72 hours) are often useful for excessive respiratory secretions. Mouth Care Opioids and hyoscine may cause dry mouth regular mouth care should be performed. Syringe Drivers In palliative care, when the parenteral route becomes necessary for symptom control, the use of syringe drivers to administer continuous subcutaneous infusions can be useful to reduce the discomfort of repeated injections. Commonly used drugs given via continuous subcutaneous infusion include opioid analgesics, antiemetics, sedatives and anti-secretory agents. Most drugs can be diluted with water for injection for continuous subcutaneous infusion. Luer-Lok syringes should be used. When given subcutaneously, diamorphine is preferred over morphine because it is more soluble so can be made up in smaller volumes which are suitable for subcutaneous use. Daily oral or IV morphine requirements can be used to calculate equivalent daily subcutaneous diamorphine doses; Total daily dose of oral morphine: total daily dose of subcutaneous diamorphine = 1: 0.33 Total daily dose of IV morphine: total daily dose of subcutaneous diamorphine = 1: 0.66 Caution must be used when using Graseby pumps to administer subcutaneous infusions to ensure the correct rate of administration, because the rate of delivery is set in either mm per hour (MS16A device) or mm per 24 hours (MS26 device). The rate of delivery is calculated by measuring the length of infusion fluid in the syringe. Once the drug to be administered as a continuous infusion over 24hours is diluted to the volume required the length of infusion fluid in mm can be determined by measuring the length in mm from the top of the syringe barrel to the top of the plunger. Graseby MS16A Rate (mm/hr) = measured length of infusion fluid in mm delivery time in hours. Graseby MS26 Rate (mm/24hours) = measured length of infusion fluid in mm delivery time in days. If a patient is receiving several subcutaneous infusions, it may be possible to mix both drugs in one syringe to avoid multiple infusion sites check the compatibility of the combination with a Pharmacist before proceeding. The site of subcutaneous infusion should be monitored to check for precipitation of drug, local reactions, fluid accumulation and inflammation. Summary The palliative care of infants is important, and follows the same principles as in older children. There should be a focus on relieving pain and distress, and opioids remain the most commonly used medication. Unfortunately, many of the other medications used in older children, accumulate in babies and this can cause problems if these medications are used in the longer term. The treatments discussed are by no means comprehensive- in difficult cases it would be advisable to seek the advice of a Neonatologist or a neonatal pharmacist. References BNF for children, 2006. BMJ Publishing Group Ltd, London. Guys, St Thomas & Lewisham Hospitals Paediatric Formulary, 7th edition 2005. Dickman, Schneider & Varga. The syringe driver, 2nd edition, 2005. Oxford University Press. Rudd N. A guide for prescribing for patients with advanced malignancy, 1998. Leicestershire Cancer Centre. PAIN ASSESSMENT Assessing pain in children with life-limiting illness can be complex but is assisted by building a relationship with the child and family, understanding the context in which pain occurs and being familiar with the childs medical condition. The object of pain assessment is to capture the various dimensions of the pain, including:- location, intensity, character (for instance is it burning or sharp?), the significance or meaning of the pain for the child and family. Pain Measurement The main purposes of pain measurement are to quantify the experience, monitor the effects of treatment, provide a shared medium through which the child can communicate the experience to others. Childrens self-report of pain Children are less able than adults to quantify and qualify abstract phenomena so any measures of pain need to be appropriate to the child's cognitive and developmental level. It should be born in mind that during illness children may be less able to use tools designed for their age and cognitive ability. There are several tools that can help the child to communicate their pain to others. It is sensible to have a few that are well known to your practice. Pain Location Body map The child can be asked to indicate on a body outline (or themselves) where the pain is. Children could also be asked to choose colours which signify different levels of pain and use these to colour in the painful areas. Pain intensity Faces pain rating scales Faces scales consist of a number of cartoon type faces in which the facial expression varies on one end with either a smiling face or a neutral (no pain) face to an expression which signifies extreme pain. The child is asked to identify their own pain intensity from the faces offered. Faces pain scales are suitable for children who are at a developmental age of five or above. Adolescents may find the tool tiresome if used over the longer term and may prefer a straightforward Numerical Rating Scale (NRS). The Wong-Baker Faces Pain Rating Scale is probably the most commonly used. Copies can be downloaded from the web for clinical use. Web page listed at end. Numerical rating scales Children must have a sound understanding of language, order and number to be able to use either the verbal or the numerical scales, probably 7-8 years upwards. Ask the child how bad their pain is on a 0 to 10 scale, with 0 being no pain and 10 being as much pain as you can imagine. Verbal pain rating scales Four to five point categorical scale with pain ratings from no pain to severe, or very severe pain i.e. pain is none, mild, moderate, severe, very severe. Parents as proxy reporters of their childs pain. When children are unable to rate their pain, parents or clinicians can provide a proxy rating. The source of these ratings is usually the childs behaviour in relation to their non-pain behaviour, the context in which the behaviour is taking place, and the provider of the ratings own attitude towards pain. As with the children themselves, parents may place particular meaning on a change in the childs behaviour and this can be explored. Assessments can sometimes vary between proxy raters of the childs pain, and it is helpful to discuss and explore the reasons for any differences. Behaviours that signal pain There are categories of pain cues that, whilst the emphasis may change with age, are common across all ages, these include changes in facial expression vocal sounds bodily posture movements mood Facial expression and cry are widely discussed in the literature on neonatal and infant pain, but their importance as indicators of pain appears to decrease with age. This downward trend is associated with, in normal circumstances, the development of a wider repertoire of behaviour which includes language. Consequently, older children are normally less likely to emit behaviours with high signal value such as crying and grimacing ADDIN EN.CITE Fridlund19973587Fridlund, A.J.1997The new ethology of human facial expression Russell, J.A.Fernandez-Dols, J.M.The Psychology of Facial ExpressionCambridgeCambridge University Press103-129. In addition, as children mature they learn to moderate their behaviour in line with the expectations of the culture within which they live. Children who are unable to communicate verbally or by augmentative means are wholly dependant upon their carers correctly interpreting their behavioural cues of pain The Paediatric Pain Profile (PPP) has been developed for children with severe neurological impairments. The 20-item behaviour rating scale is incorporated into a parent-held document which can be downloaded. See below for link. Pain diaries and flow sheets Ask parents, children or carers to keep a pain diary or a flow sheet, where space is provided to write the time, duration, context in which pain has occurred, pain measurement on one of the above tools or suitable alternative, the intervention and the outcome of the intervention using the same pain measure. The use of a standard pain measure will help to evaluate the effectiveness of different interventions. Some useful web resources International Association for the Study of Pain. Pain assessment in children HYPERLINK "http://www.iasp-pain.org/PCU95b.html"http://www.iasp-pain.org/PCU95b.html Cancer Page. Pain relief for children. HYPERLINK "http://www.cancerpage.com/centers/pain/pediatrics_p.asp"http://www.cancerpage.com/centers/pain/pediatrics_p.asp Wong Baker Faces Pain Rating Scale HYPERLINK "http://www3.us.elsevierhealth.com/WOW/fyi03.html"http://www3.us.elsevierhealth.com/WOW/fyi03.html Paediatric Pain Profile, a behaviour rating scale for children with severe to profound neurological impairments HYPERLINK "http://www.ppprofile.org.uk"http://www.ppprofile.org.uk Institute of Child Health, Childrens pain assessment project HYPERLINK "http://www.ich.ucl.ac.uk/cpap/"http://www.ich.ucl.ac.uk/cpap/ Eland colour tool and other faces scales HYPERLINK "http://www.stat.washington.edu/TALARIA/attachment.html"http://www.stat.washington.edu/TALARIA/attachment.html A pain flow sheet. HYPERLINK "http://www3.us.elsevierhealth.com/WOW/op020.html"http://www3.us.elsevierhealth.com/WOW/op020.html To purchase the World Health Organisation book - Cancer Pain in Children HYPERLINK "http://www.tso.co.uk/bookshop/bookstore.asp?FO=1160671&DI=352971"http://www.tso.co.uk/bookshop/bookstore.asp?FO=1160671&DI=352971 PAIN The commonest expressed fear in paediatric palliative care by parents is that their child may experience pain. Fortunately in the majority of cases, pain control is relatively straightforward and easier to manage than some of the other symptoms. The whole topic of pain is so vast that this section can only represent a synopsis of the basics of cause and management. In more complex cases it is worth consulting with local hospices, pain clinics and paediatric consultants. Determining whether a child is in pain, or the level of that pain is not easy. Various pain-scoring techniques have been developed and if one has knowledge of these, they are worth trying. However in most cases, parents and experienced nurses can provide invaluable information from their knowledge of the childs behaviour. Older children can often describe pain but only in the context of their experience related to their age. A good history and knowledge of pathogenesis of the disease will help to direct one to the underlying cause of pain. Causes Direct visceral involvement Bone involvement Soft tissue infiltration Nerve compression Nerve destruction Raised intracranial pressure Muscle spasm Colic / constipation Gastritis Retention of urine Psychological As with all the other symptoms it is worth remembering to listen, look and examine before rushing in with medication. Not all pain can or needs to be controlled with opiates. It is relatively easy to feel or percuss a childs bladder. Pain from direct tumour spread will often improve by reducing inflammation around the tumour with non-steroidal anti-inflammatory drugs or steroids. Good nursing and social support can help the child and family cope with pain. Religion and/or strong faith can modify perceptions of pain. Alternative medical practises such as herbal, reflexology etc. may be of help in the future as we learn more about them. The only rule in pain control is that there are no rules; you need do whatever it takes to help the child out of their pain. Treatments There are numerous drugs on the market for pain control. It is always best to get to know one or two drugs from each group well. Using the ladder system of increasingly stronger drugs within each group is a useful tool in general medicine. In paediatric palliative care however it is best to change to a stronger group if one medication does not work. WHO Pain Ladder Pain control should follow the rules laid down by the WHO pain ladder, i.e. start at the bottom of the ladder and work your way up depending on the severity of the pain and the control achieved. If treatment at one level does not work then do not try other drugs of the same level, but go up the ladder. Use adjuvant therapy at any level of the ladder.  SHAPE \* MERGEFORMAT  Non-opioids Paracetamol is the drug of choice in mild pain. Its antipyretic effects are also very helpful with concurrent infections. Administration is aided by the fact that it comes in so many strengths and forms. Ibuprofen is often used specifically by families, as it is available over the counter. Ibuprofen has a mild antiplatelet effect and should be used with caution in patients with a bleeding tendency. Weak opioids Codeine Phosphate or Dihydrocodeine are the drugs of choice in moderate pain. Both drugs suppress the cough reflex and cause constipation. They also both have a maximum dose limitation above which they do not provide any increase in benefit. Strong opioids There is often great hesitancy shown from parents and carers about initiating morphine. There are a great many fears and myths surrounding its use. It is very important that before starting any treatment these issues are addressed and the parents and child are aware of the truth. Myth: It will shorten the childs life. Truth: Pain control does not shorten a childs life; it only brings comfort to a childs death. It can even extend a childs life because they are not exhausted from fighting pain. Myth: It will suppress a childs breathing. Truth: Respiratory depression can be avoided by steady increases of dose. Myth: It will give the child nausea. Truth: Nausea may occur in 25% of cases but will normally settle in 5-7 days. Myth: It will make the child even more constipated. Truth: Constipation must be prevented by the early use of prophylactic laxatives. Myth: They will develop addiction to it. Truth: Addiction is not a problem encountered in paediatric palliative care. Myth: Sedation will affect the quality of the childs life in the final days. Truth: Sedation will normally improve within a few days of taking morphine. Myth: It is the beginning of the end. Truth: Our experience is that children will often live longer than we expect. Also dosage can be reduced or increased depending on the childs state. Also It is not a problem to wean children off morphine should they improve for a while. Children metabolise opiates very well: their excretion through the kidneys is, if anything, better than adults. There is no evidence to suggest that morphine gets into the CSF of children any more than it does in adults. The opioids have no upper limit effect. Incremental increases in dose should be of the level of 30-50% or based on previous days breakthrough pain dose. The morphine based products come in numerous types and forms. It is best to get to know a few well and keep the rest for specific uses. Liquid morphine is often the best way to start, using it on an as required bases (clinical skill, judgement and knowledge of the child should be used in children unable to communicate). After a few days the child can be converted over to slow release morphine with additional liquid morphine for breakthrough pain. The conversion factor is one to one. Slow release morphine is available in tablet and granular forms. Once a child is unable to take preparations orally then it is worth thinking of either fentanyl patches or diamorphine infusion. Fentanyl patches come in various strengths. A few key points need to be observed when using them. Unfortunately the size of the stronger patches can be a problem in the smaller child, The old reservoir patch cannot be cut. The new patches are matrix based and in theory may be cut but this is not advised by the manufacturer. The strength of patch to use is dependent on the morphine dose and conversion has to be done correctly. They take 12 hours to reach therapeutic plasma levels. If converting from 4 hourly oral morphine, then continue to use morphine for 12 hours. If converting from slow release morphine, then apply patch at same time as last oral dose. Fentanyl patches have the advantage of lasting 72 hours each and provide a level release of opiate. They also cause less sedation, less respiratory depression and less constipation than morphine. Fever and external heat (from hot baths, hot water bottles, radiators etc.) increase the rate of absorption and can cause toxic effects. Because they do not involve using needles and can be administered by a competent parent, they tend to be fairly well received by the families. Diamorphine infusions can be given via a central line or subcutaneously. Diamorphine has the advantage of being highly soluble and can be mixed with other drugs. This mode of administration allows constant levels of analgesics with the benefit of greater dose variations and the ability for parents to give boost doses via syringe drivers. Dose conversion is based on one third of the total oral dose of morphine over 24 hours. Maximum solubility of diamorphine is 400mg/ml. Oral diamorphine and morphine are equipotent. Peak blood levels of intravenous diamorphine are approximately double that of a s.c. or i.m. dose. Peak plasma levels of morphine / diamorphine occur approximately 30mins after i.m. or s.c. injection, but 2-3 hours after setting up a continuous s.c. infusion. Subcutaneous injection or infusion of diamorphine is 1.5 times as potent as morphine (e.g. 15mg morphine s.c. = 10mg diamorphine s.c.). Oral morphine is only half as potent as by injection. Thus oral morphine dose conversion to diamorphine subcutaneously or by infusion is one third (e.g. 30mg morphine p.o. = 10mg diamorphine s.c.). For breakthrough pain give a dose of oral morphine 50-100% of the 4 hourly equivalent dose. Buccal or intranasal diamorphine may be useful for rapid pain control. Two side effects of opioids that appear to be more common in children are urinary retention and pruritus. Urinary retention may improve with carbachol or bethanechol Pruritus can be treated with topical treatments (calamine lotion, Eurax, hydrocortisone creams) or oral antihistamines. Ondansetron and oral naloxone have also been used. Reducing the dose of opioid or changing to an alternative such as fentanyl can also help. Oxycodone is an alternative opioid analgesic used as second or third line treatment in patients who are unable to tolerate morphine. It is not licensed for use in children under the age of 18 years. It comes in 3 forms OxyContin prolonged release tablets (every 12 hours) The tablet is biphasic with initial fast release providing early onset analgesia followed by controlled release over 12 hours. Morphine equivalence is 2:1 (20mg oral morphine = 10mg oral Oxycodone). The tablets can not be crushed, broken, chewed or halved. The tablet matrix is insoluble and may be passed in stools (the drug will have been absorbed in the GI tract). Breakthrough pain dosage is 1/6th total 24 hour dose. OxyNorm immediate release liquid or capsules (every 4-6 hours) The capsules can not be opened The liquid can be mixed with soft drinks and contains no sugar There is no data on administration down an NG tube. OxyNorm 10mg/ml, solution for injection or infusion Can be given i.v. or s.c. by injection or infusion Can be diluted in 0.9% saline, 5% dextrose or water for injection Conversion ratio for oral to parenteral Oxycodone = 2:1 Conversion ratio for parenteral morphine to parenteral Oxycodone = 1:1 Conversion ratio for parenteral diamorphine to parenteral Oxycodone = 1:1 OxyNorm injection is stable for 24 hours at room temperature and need not be protected from sunlight. See appendix for compatibility with other drugs Hydromorphone use in the paediatric setting is currently unclear. It is an alternative opioid analgesic used as second or third line treatment in patients who are unable to tolerate morphine. It is licensed for use in children from age 12 years. It comes in 2 forms a slow release capsule and standard release capsule for breakthrough and incident pain. It can be used if there is renal impairment. The capsules can be opened and sprinkled onto cold soft food (swallow without chewing: chewing SR formulations can lead to over dose). Morphine equivalence is 7.5:1 (30mg oral morphine = 4mg oral hydromorphone). NSAID Inflammation can cause pain either directly or by adding to pressure e.g. tumours in bones. Anti-inflammatories such as diclofenac, naproxen or indomethacin can be very effective in these cases. Piroxicam is available as oral melts. Be watchful for dyspeptic symptoms, which are a common side effect and can be reduced by concurrent use of prophylactic omeprazole or misoprostol. The new Cox-2 selective NSAID e.g. celecoxib may be helpful although many of these types of NSAID have been withdrawn due to cardiac side effects. Oral ketorolac is very effective for short-term postoperative pain relief and the intravenous form can help with severe pain from soft tissue or bony metastases, if this has been poorly responsive to other NSAID. Steroids Steroids particularly dexamethasone, can help reduce pain from raised intracranial pressure, bone pain and pain from nerve infiltration. Used in short courses they can be very effective. Unfortunately long-term use can cause problems including: - Mood and behaviour problems Weight gain and changes of appearance Reduced mobility Insomnia Dyspepsia Peptic ulceration Oral or oesophageal candidiasis Psychosis Antidepressants Pain due to nerve compression or destruction (often described as burning pain) can be modified with the use of certain tricyclic antidepressants e.g. imipramine, amitriptyline or doxepin. Benefit should be seen within 3-4 weeks. If the is no response then it is worth changing to an anticonvulsant. Anticonvulsants Stabbing pain from nerve damage can be modified with the use of certain anticonvulsants e.g. carbamazepine or phenytoin. Gabapentin is now also being used with good effect. Benefit should be seen within 3-4 weeks. If the is no response then it is worth changing to an antidepressant. Other drugs Methadone is used in parts of the world although experience in the UK is limited. Difficulties with its long plasma half life and broad-spectrum receptor affinity limit its uses to specialist units The intravenous preparation of ketamine given orally can be useful for resistant neurogenic pain. However it is not always well tolerated and bioavailability is unpredictable, as such its use should be limited to specialist units. Nitrous oxide given by facemask can be useful in the older child. Bisphosphonates have been used for bone pain in children. Hyoscine butylbromide is the initial treatment of choice for colicky abdominal pain. Beware the use of opioids with this type of pain. Radiotherapy Even in cases where therapeutic radiotherapy is no longer appropriate, pain from bone or soft tissue malignant deposits can be treated with palliative local radiotherapy. Nerve blocks This form of treatment is best left to specialist pain clinics. Our experience in paediatric palliative care of this is limited. Nursing and Supportive Care Good nursing care is beyond value. A child who is in pain or distress can be seen visibly to improve and settle just by being held and hugged. The reassurance of physical contact and affection can and does modify perceptions of pain. Spirituality / Religion Whether the carers concerned believe that religion modifies perceptions of pain is irrelevant. What matters is what the child and family believe. Our job is to use all the means available to aid the child, and to that end religion and faith is a most powerful tool in appropriate cases. Other There appears to be an emergence of a number of alternative medical practises, acupuncture, reflexology, aromatherapy, herbal medicine etc. Just because we do not necessarily understand how these work does not mean we should ignore them. Some may in the future become useful additions to our armoury against pain. Table 20: Oral analgesic equivalence to morphine Multiply drug dose with potency ratio to obtain equivalent dose of morphineAnalgesicPotency ratio with morphineCodeine / Dihydrocodeine1/10Oxycodone1.5-2Methadone5-10Hydromorphone7.5Fentanyl (transdermal)150 Adapted from Symptom Management in Advanced Cancer by Robert Trycross Table 21a: Drugs used to treat pain DRUGROUTETOTAL DAILY DOSE (T.D.D.)TIMES DAILY (Divide T.D.D. by this figure)1 month to 12 yearsOver 12 yearsParacetamolOral or rectalUnder one year 10-15mg/kg (Single dose)0.5-1g (Single dose)Single dose, may repeat every 4-6hrly. Max 4 doses in 24hrs1-5 years 120-250mg (Single dose)6-12 years 250-500mg (Single dose)Codeine PhosphateOralOver 1 year 3-6mg/kg180mg4 6DihydrocodeineOral1-4 years 2-3mg/kg120-180mg4 64-12 years 2-6mg/kg (Maximum 1mg/kg/dose)MorphineOral or rectalUnder one year 80microgram/kg (Single dose)10-15mg (Single dose)Single dose, may repeat up to 6 times in 24hrs1-12 years 200-400 microgram/kg (Single dose)DiamorphineIV infusion12.5-25 microgram/kg/hourContinuousSC infusion20-100 microgram/kg/hourOxycodoneOral (in opioid nave)0.2mg/kg (Single dose)5-10mg (Single dose)Up to 6 times in 24 hours Convert to modified release preparation once optimal doses are achievedOral (patients already on opioids)1/12 times total equivalent daily dose of morphine (Single dose)DiclofenacOralOver 1 year 3mg/kg75-150mg2-3NaproxenOral10-15mg/kg500-1000mg2-3IbuprofenOral20mg/kg0.6-1.8g3-4Ketorolac (Maximum duration 48 hours)Oral2-12years 1-4mg/kg4IV bolus0.5mg/kg bolus followed by EITHER 1mg/kg every SIX hoursIV infusion OR 0.17mg/kg/hourContinuousOmeprazoleOral0.7-3 mg/kg1-2MisoprostolOralNo dose recommendation if required estimate by age or body surface area800microgram4 Table 21b: Drugs used to treat pain DRUGROUTETOTAL DAILY DOSE (T.D.D.)TIMES DAILY (Divide T.D.D. by this figure)1 month to 12 yearsOver 12 yearsDexamethasone 2mg/5mlOral1-6mg2ImipramineOral200-400 microgram/kg Increasing by 50% every 2-3 days To 1-3mg/kgAt night. Start at lower dose and titrate against pain / side effectsAmitriptylineOral-30-150mgAt nightCarbamazepineOral5-20mg/kg800-1200mg2-3 Start at lower dose and titrate against pain / side effectsPhenytoinOral5mg/kg Then 5-15mg/kg (Maximum 300mg per day)150-300mg Then 300-400mg (Maximum 600mg)2Ketamine (Only for specialised units)Oral0.1-0.3mg/kg/hrMaximum 1.5mg/kg/hrMethadone (Only for specialised units)Oral starting dose2-12years 0.2mg/kg as a single dose5-10mg as a single doseGive single doses every 4-12 hours PRN After 48 hours calculate total dose of methadone given over 48hours. Divide this figure by four to give 12 hourly doseIV or SC starting dose0.1mg/kg as a single dose5-10mg as a single doseHyoscine butylbromide Oral IV bolus IM SC 24hrly infusion 1month-2years 1.5mg/kg 2-5 years 15mg 6-12 years 30mg80mg 3-4 Table 22: Dose conversion of morphine to Fentanyl patches DOSE CONVERSION OF FENTANYL PATCHES4 HOURLY ORAL MORPHINE (mg)<2025-3540-5055-6570-8085-95100-110FENTANYL PATCH STRENGH25507510012515017524 HOUR ORAL MORPHINE DOSE (mg)<135135-224225-314315-404405-494495-584585-674SPIRITUAL PAIN Suffering is not a question that demands an answer; it is not a problem that demands a solution; it is a mystery that demands a presence. (Source unknown). INTRODUCTION. Spirituality and spiritual care are the proper concern of all who work with you as a family. It should be recognised that the issues of spirituality and religion are very important. However, they are two different aspects of care. It has been suggested that we all have a spiritual dimension and needs, and some people also have religious needs. It is possible to have spiritual needs independently of religious needs. Religious needs are to do with a shared faith, beliefs, practices and rituals that help a person make a connection with their God. Spiritual needs are to do with our search for meaning and purpose and a sense of well-being and wholeness. Somebody once said that it puts us in touch with both our freedom and our destiny, enabling us to find our selves and find our way with others. These next few pages are not about answering all the questions you may now have about Why my child or Why our family or What is the meaning of life and all those very difficult questions you now face with your child and family. Nobody can give you the answers to these profound questions you, your family or your child now ask. Within this section no answers are given, but it is suggested that you do something that is far from easy for anyone to do. That is to sit with your child and try and stay in that difficult place and listen to your childrens questions and hear their fears. You will not be failing your children by not knowing the answers to some of the questions they may now have. Not knowing can be a place of strength and maybe even reassuring for your child. I once read a book which that was called, Failure, the gate way to hope, which I found very reassuring in itself. We wont always get it right, so dont expect to. Dont go looking for perfection. You will struggle with your own doubts as well as those of your child and family, but the struggle will be worth it. The next few pages focus on the needs of your child who is ill, but they are just as applicable to you as parents or to your other children. I would suggest that we all have spiritual needs to which we must attend. Our spirituality is something that cannot be turned on and off at will, it is a part of us and is always present. Your spirituality cannot be isolated from all that makes you who you are, or your family who they are. All sick children will at some time think about what is going on, not only in their bodies, but also in their inner worlds. On this journey they need you to sit with them, in effect to watch with them, wait with them and let them wonder. They need you to be their companion, their guide and their advocate. However, the most you can do is to prepare and hold that space where they can start to do the work they need to do for the next stage of their journey, where they can explore their inner-world and where the miraculous may happen. You now find yourself on a journey, a journey that you have had very little choice about making, and would have preferred not to have started. I have suggested that this is about a journey to the centre, to the heart of the matter, to our deep centre, where sometimes we meet our pain and have to name it. Children do come ready equipped for their spiritual journey, in so far as they have an openness and awareness, which in a way is unique to a childs early years. As we get older this openness and awareness gets pushed to one side. DEFINITION: Spirituality is what gives a persons life meaning. It is about how people view the world they find themselves in and this may or may not include a God figure or a religious faith. Spirituality is about how we view the world and how we react within it. In talking about spirituality we need to bear in mind that we all come from different social and cultural contexts, that we each have a past and some of us have a future; and it is out of this setting that our spiritually will manifest itself. It is from this background or setting that your childs questions will flow. Therefore, you may well be the best person to offer this aspect of care, with help and support from others around you. I have found that children with a life-limiting or threatening illness have a highly developed sense of their own spirituality, though they may not say or show it directly. It may well be deeper and more mature, than other children of their age and development. However, they may not always have the words or means of expressing it. Therefore, you as parents are very important, because you will be able to understand your childs language and play far better than anyone else. PRACTICALITIES: If we are to understand our children, their spirituality and their needs, we must first reflect on our own spirituality and be prepared to question our own assumptions about spirituality and religion. How do we see spirituality in our own lives and the psychological influence it may have had on us coming from some distant place in our past? The current situation in which you find yourself will challenge your value systems and notions of spirituality and cause you to reflect deeply. This process of questioning often happens and you need to know that it is not unusual and you should not be wracked with guilt for questioning. Spiritual care is about responding to the uniqueness of your children and accepting their range of doubts, beliefs and values just as they arise. It means responding to the spoken or unspoken statements from the very core of your childrens being as valid expressions of where they are and who they are. It means being their friend, companion and their advocate in their search for identity on their longest journey and in the particular situation in which they now find themselves. It is to respond to them without being prescriptive, judgemental or dogmatic and without preconditions, acknowledging that your child and other members of the family will be at different stages on this very painful spiritual journey. In order to be able to respond to this call, you need to try and create a safe and secure place, which I have come to call a sacred space, where your children can express their inner suffering and know that it is alright to do so, that they will be heard and taken seriously. You can help them best by just sitting with them, watching with them, waiting with them and just wondering. Take your lead from them, go with them, do not try to direct them, and use the language and imagery they use. We need to be open to what our children have to teach us. We need to be prepared to learn from them. The skill here, as in other aspects of your childrens care, is to be able to understand or crack their code. We can start to do this, if we just sit with them, if we learn to watch, wait and wonder with them, if we take our lead from them, and be responsive to their needs and not the needs we think they may have or our own needs. Never underestimate your childs understanding of what is going on. You do so at your peril. You may be surprised at how your child has an unclouded, clear way of thinking and their "take" on abstract ideas is often quirky, but relentlessly practical. This is the way in which they can help us with our struggle in trying to understand their suffering. You may have discovered for yourself by now that you cannot fill the hole in a doughnut as much as you try to fill it, it just keeps disappearing out the back into some black hole. What you need to remember is that when you are with your child, the spaces or the gaps in the conversation do not need to be filled. This may be the centre of their journey and you just need to hold that space with your child and be present with them. Suffering is not a question that demands an answer; it is not a problem that demands a solution; it is a mystery that demands a presence. (Source unknown). PSYCHOLOGICAL The whole subject of child psychiatry in paediatric palliative care is vast and complex. The symptoms that present are more often a reflection of the internal stresses and strains within a family. Helping the parents cope with a particular illness is as important as helping the child itself. All parents with healthy children who have been up with them a few nights during a trivial illness will have a brief understanding of the tiredness, fatigue, frustration and worry that is constantly felt by the parents of children in the hospice. The children themselves can also be left feeling frightened and guilty about their illness. There is no magical secret in helping these children and families. It requires good old-fashioned care and compassion. We need to give the family our time and we need to be prepared to listen. Giving honest answers to straight questions can allay fears and anxieties. A doctor or specialist counsellor is not necessarily the best or only person to tackle these issues. Our experience is that children and their families often prefer to talk to the nurses, teachers or priests. All these carers will, however, need support to cope themselves with the issues. When, however, despite our best efforts, a child is manifesting clinical symptoms of anxiety or depression, then we must not be afraid of using medication as an adjuvant to our counselling and support. Symptoms manifested by children are not the same as those manifested by adults. They are also very dependent on the age and development of the child. Younger children tend to regress and develop behavioural problems; older children may have nightmares, insomnia or become introspective. It is very difficult without experience to diagnose many of the psychological problems that these children can get. Fortunately a child psychiatrist can be very helpful and supportive. Also it is worth trusting the natural instincts of the parents and nurses who often know the children better than we do. Anxiety, particularly in the terminal stages can be helped with a number of drugs each of which can have different benefits. Midazolam and methotrimeprazine are two of the first line drugs for treating anxiety (although midazolam can cause paradoxical agitation). Chlorpromazine works well and its sedating effects can be helpful in certain cases. Diazepam also has sedative effects and its rectal form can be used in urgent cases when agitation is a major problem. Haloperidol has an important role in treating confusion. Insomnia is a problem not only for the child but also for the parents. Parents may benefit from the use of complimentary therapies, particularly aromatherapy and massage, which can help to reduce tension and anxiety and promote relaxation and hopefully sleep. Temazepam can be used for the older child. Triclofos is useful in the younger child. The antihistamine promethazine can be used in the milder cases. Melatonin can help in managing insomnia and appears to be used increasing in children with special needs. However it is unlicensed in the UK for this and so many general practitioners may feel unhappy about prescribing it. Depression treatment has the disadvantage of taking 2-3 weeks to work. The older child may benefit from serotonin re-uptake inhibitors such as fluoxetine. Paroxetine has been used in the past but is now no longer licensed for use in children due to its side effects. There is currently a lot of controversy about the other forms of serotonin re-uptake inhibitors (except for fluoxetine) and in view of this it is probably best to avoid them unless there is no other option. The young child can be treated with tricyclics such as imipramine. Parents and other family members may also require medical treatment. Table 23: Drugs used to treat psychological problems DRUGROUTETOTAL DAILY DOSE (T.D.D.)TIMES DAILY (Divide T.D.D. by this figure)1 month to 12 yearsOver 12 yearsHaloperidolOral 50microgram/kg (maximum 10mg) 1.5-20mg (maximum 60mg)2LevomepromazineOralN/A50-100mg4SC infusion0.35-3mg/kgContinuousChlorpromazineOral1-5 years 500microgram/kg Single dose given every 4-6hr (maximum 40mg/day) 75-300mg3 Adjust dose according to response6-12 years 30-75mg/dayDiazepamOral1 month-1 yr. 500mcg/kg6-30mg2-31-4 years 5mg5-12 years 10mgTemazepamOral1mg/kg20mgSingle doseTriclofosOral30-50mg/kgSingle dose at nightPromethazineOralUnder 1 year 5-10mg25-50mgSingle dose at night1-5 years 10-20mg5-12 years 20-25mgImipramineOral6-7 years 25mg75mgAt night8-11 years 25-50mgOver 11 years 50-75mgFluoxetineOral20mgSingle dose SEIZURES The child who has seizures falls into one of two categories. 1. The child with a neurodegenerative disorder who has had multiple seizures and is on a multitude of anti-epileptics. The parents are normally relaxed and knowledgeable about the seizures and how to treat them. 2. The second case is linked to malignant disorders and here seizures are a new and frightening complication of the illness for the parents. A calm and gentle warning to the parents of what can happen; with a positive explanation of what can be done to reduce the childs distress may help to reduce the parents shock. Equally, the care team members who are not experienced with a fitting child may find the experience distressing. It is however important that seizures are managed in a calm and logical manner. Rule one is that not all seizures are grand-mal epileptic seizures; they come in many forms and it is important to recognise the different types. Rule two is that not all seizures require immediate administration of diazepam. The majority of seizures will settle given a bit of time. Simple seizures can be left 10-15minutes, particularly in the neurodegenerative disorders before administering diazepam. Rule three look for reversible causes of increased seizures and try to correct them e.g infection, biochemical imbalance, hypoglycaemia, raised intracranial pressure and inappropriate epilepsy management (see intractable epilepsy) The first line of treatment for persistent seizures is diazepam. Although it can be given intravenously, obtaining a new access site is difficult. It should be given rectally as a solution because suppositories take too long to work (there is no justification for rectally administered medication if the child already has a gastrostomy or naso-gastric tube).If given intravenously its has an onset of action in 1-3 minutes but a short duration of action of 15-20 minutes. It is effective in 80% of cases with control in 5 minutes. Intra-muscular injections should not be used in palliative care. The dose can be repeated once 5-10 minutes later. If there is still no response then rectal paraldehyde should be administered. Paraldehyde should be given mixed in an equal volume of arachis oil (or olive oil if there is any nut allergy), drawn up into a glass syringe and given via a quill (if urgent a plastic syringe can be used provided it is drawn up and given immediately). In the terminal stages seizures tend to become more severe and frequent. The child at this stage is normally not able to take or absorb oral anti-epileptics and in such cases continuous subcutaneous midazolam or phenobarbitone can be used. Both drugs are also good anxiolytics. Clonazepam is an alternative to midazolam. Midazolam can be mixed with diamorphine in a syringe driver. It has an onset of action of 1-5minutes and duration of action of 1-5 hours. The main problem with midazolam is that it comes only in one strength, as a result the volume in a Graseby syringe driver can become a problem. In such cases it is best to split the dose over 12 hours rather than 24 hours. Anecdotal evidence suggests that a small dose of diamorphine added to the syringe driver can help with seizure that are requiring increasing doses of midazolam. Buccal midazolam can be used instead of subcutaneous or intravenous infusion, the intravenous formulation of 10mg in 2mls given in the appropriate dose buccally. Phenobarbitone has a slower onset of action but a much longer duration of action 24-72 hours. Intractable Epilepsy The management of intractable epilepsy is beyond the scope of this manual. But it is worth remembering a few basic points 40% of children with epilepsy are misdiagnosed. This can be due to Underlying aetiology overlooked Misdiagnosis of syndrome and seizure type Poor EEG recording and interpretation Non epileptic disorders that mimic epileptic disorders There are often errors in therapy due to Inappropriate choice of drugs Inappropriate dose and dosing interval. Inappropriate polytherapy In all cases of children with intractable epilepsy check that 1. The child has actually seen a Paediatric Neurologist and has had a formal diagnosis of type of epilepsy made. 2. Regular re calculation of drug dosages are made as the child grows and put on weight 3. If the child is on polytherapy has this decision been made by a Paediatric Neurologist and if not what is the rational for the polytherapy. Table 24: Drugs used to treat seizures DRUGROUTETOTAL DAILY DOSE (T.D.D.)TIMES DAILY (Divide T.D.D. by this figure)1 month to 12 yearsOver 12 yearsMidazolamSC or IV infusionLoading dose 0.15mg/kg Maintenance dose 50-300 microgram/kg/hourOver 150mg consider changing to phenobarbitoneIntranasal200-300microgram/kg/single doseUnpleasant taste and irritating to nasal passagesBuccal500microgram/kg/single doseUp to 10mgDiazepamRectal solutionUnder 1 yrs 2.5mg10mgSingle dose. Repeat after 5 minutes if necessary1-3 years 5mg4-12 years 5-10 mgParaldehyde special enema 50%in arachis or olive oilRectal0.8ml/kg of prepared enema10-20ml of prepared enemaSingle dosePhenobarbitoneSC or IV infusionLoading dose 15mg/kg Then maintenance dose over 24 hours5-10mg/kg600mgClonazepamIV bolus over 30 seconds50micrograms/kg (Maximum 1mg)1mgSingle dose. Can be repeatedIV infusion10 microgram/kg/hrContinuous. Up to 60 microgram/kg/hr have been givenLorazepamIV slowly Rectal Sublingual50-100 microgram/kg4mgSingle dose, repeated once 24 hours later if necessary. IV injection can be given rectally or sublingual SKIN Management of skin problems is often challenging. This is one subject where prevention is better than cure. Our children are often wasted and immobile. Because the metabolism of the body enters a catabolic phase during severe illness the skin becomes very vulnerable to breakdown and subsequent poor healing. Good nursing care is required to predict where potential problems may occur. Special mattresses, aids and appliances can be organised. Turning of the child needs to be frequent and regular. Skill is also required in knowing how to move the child. Hoists and harnesses may be needed. Initial problems tend to start from pressure sores or friction burns. The skin at this stage can be protected with OpSite, Tegaderm or Cutifilm. Care must be taken when removing these dressings so as not to further damage the skin. Once it breaks down then DuoDerm or Spyrosorb can be used. Infected skin ulceration will require IntraSite gel or Iodosorb paste to remove discharge or necrotic tissue (top dressings can be OpSite or Tegaderm). Cavities can be packed with Kaltostat or Sorbsan. Re-dressings are done as required depending on the amount of exudate. Oral antibiotics may be necessary if cellulitis or discharging pus is present. Because many of the children may be on anti-epileptic drugs, erythromycin must be used with caution. Fungating tumours when infected can be very smelly. This causes great distress to the child and family. Metronidazole orally or topically is very effective and a deodoriser can help. The skin can also be dressed with Actisorb (charcoal dressing) to help reduce the smell. Honey and sugar can be used topically to reduce the smell of ulcers and they are also bacteriostatic. Table 25: Types of dressings and their use TypeExampleBenefitNotesFilmsOpSite, Tegaderm, CutifilmSemipermeable, totally occlusive, allow observationCannot absorb exudatesHydrocolloidsGranuflex, Comfeel, DuoDerm, Spyrosorb Occlusive but absorb exudatesFacilitate autolysis of slough and escharHydrogelsIntraSite gel, IodosorbAbsorb large amounts of exudatesUseful for cavities. Can damage healing tissue if allowed to dryAlginatesKaltostat, SorbsanHighly absorbent, HaemostaticFoamsLyofoam, SilasticHighly absorbent, Good for deep cavitiesNot for wounds with sinusesLow adherentRelease, MeporeProtects wound surface, absorb some exudatesIf dried out then wet to remove (Table adapted from commonly used dressing Symptom Management in Advanced Cancer by Robert Twycross) Flow chart of management of fungating tumours Fungating malignant wound Contributing systemic factors? Yes 1. Is the tumour disfiguring? Yes 2.  Is pain present? Yes Only at dressing changes Yes 3.   No 4. Is there exudate? Yes Is it light? Yes 5. No   Is it heavy? Yes 6.  Is it malodorous?   Yes 7. Is the wound a cavity? Yes 8. Is the wound sloughy/necrotic? Yes 9. Is debridement required?  Is the wound infected? Yes 10.  Is the wound bleeding? Yes 11.  Is the surrounding skin at risk? Yes 12. Consider potentially treatable factors Reducing or stopping steroids Improving nutrition Modify the size and appearance of the tumour Surgery by debulking or excision Radiotherapy Chemotherapy If pain present at dressing changes Short acting analgesic e.g. buccal diamorphine Topical anaesthetic agents e.g. lignocaine Entonox If pain present all the time Review analgesia Consider topical diamorphine in dressing For light exudates Semi-permeable film dressing Hydrocolloid interactive dressing Low adherent dressing Alginate dressing Hydrophilic foam dressing For heavy exudates Hydrocolloid interactive dressing Hydrogel with secondary dressing Alginate dressing Hydrophilic foam dressing Use of paediatric stoma bags For malodour consider A counter odour e.g. household air freshener, ostomy agents, aromatherapy oils. A deodorant e.g. Naturcare or electric deodoriser Metronidazole either topically or systemically Live yoghurt Charcoal impregnated alginate or foam dressing Totally occlusive dressing e.g. OpSite or almost totally occlusive dressing e.g. Granuflex If a cavity is present consider Cavity dressing e.g. alginate Silastic foam if wound is clean Foam dressing If debridement is required consider Surgery Enzymes e.g. Varidase Hydrocolloid paste with dressing Hydrogel If the wound is infected Topical metronidazole e.g. Anabact or Metrotop Irrigate with IV metronidazole solution Systemic antibiotics Honey and icing sugar dressing If the wound is bleeding Calcium alginate dressing (haemostatic properties) Topical adrenaline 1 in 1000 solution Radiotherapy Use non-adherent dressings and soak dressings off with normal saline If the surrounding skin at risk Protect surrounding skin with barrier ointment Care must be taken with dressing to Remove dressings without pain To make dressings cosmetically acceptable to the child To lengthen the time required between dressing changes To understand the cost effectiveness in terms of time and money for all the different types of dressings TRACHEOSTOMY CARE What is a Tracheostomy? This is an artificial opening into the windpipe (trachea) which is held open by a tracheostomy tube. This helps the child to breathe easily; air now goes in and out through the tracheostomy bypassing the mouth. Indications for a tracheostomy a narrow upper airway the need for long term ventilation bronchial toilet There are several types of tracheostomies. They can be made of plastic or metal, may be cuffed (avoided in children), uncuffed, or fenestrated (with a hole in the canula to facilitate speech). The child will be given the one most suitable for his / her needs. All children that have a tracheostomy must at all times have with them the following: Suction machine and charger. Appropriate size suction catheters. Change of tracheostomy tube - same size and one size down. Change of ties / tapes. Scissors. Water based lubricant. Normal saline and gauze. Water to clear tubing. Gloves. Change of Swedish nose. Most importantly, a capable adult to change a tracheostomy in the event of an emergency. Prior to any procedure in relation to the tracheostomy it is important to reassure the child and explain as much as possible about the procedure to be performed. Daily Care The tracheostomy stoma needs cleaning daily as tracheal secretions can infect the stoma site. Cleaning may need to be increased if child unwell or there are a lot of secretions. The stoma site is cleaned with normal saline and a cotton wool applicator. This is a time to inspect the stoma for any signs of redness or the presence of granulation tissue (excess new skin). If there is redness / irritation a sterile keyhole dressing can be applied between the skin and the flanges, taking care not to cover the tracheostomy tube. The dressing should be changed regularly as wet dressings can cause irritation and infection. BARRIER CREAM SHOULD NOT BE APPLIED. If there is granulation tissue present discuss with Tracheostomy Nurse Specialist as this will need to be cauterised or removed. Tape Changes The tracheostomy tube is held in place by either cotton ties or Velcro tapes. These need to be changed daily or more frequently if soiled. This is a two person procedure; one person secures tracheostomy in place, while the other person changes the ties or tapes. Prior to any procedure ensure that all the necessary equipment is at hand: Two lengths of inch cotton tape or Velcro ties. Normal saline and gauze to clean the skin. Tracheostomy tubes. Suction if necessary. Position child on his / her back with the neck extended over a rolled towel. One person secures tube in place, the other cuts and removes the soiled tapes. Thread the end of one of the tapes through the tracheostomy tube flange on the far side and tie it to the other with three knots. Repeat the procedure on the other side but instead of securing the tapes with a knot, just tie in a bow. Keep the tapes as unwrinkled as possible and try to achieve the correct tension before tying the bow. Continuing to hold the tube, sit the child forward and with childs head bent forward it should be possible to place one finger between the ties and the skin. This is the safest recommended tension. If tension is correct then change the bow to three knots securely. If Velcro tapes used, remove soiled tapes, position new tapes, thread the Velcro part through the flange of tracheostomy, fasten and repeat on the other side, ensuring that the safe tension is maintained at all times. Suctioning Why suction? If secretions are allowed to accumulate they will block the tube. Secretions left in the tube could lead to infection. When to suction? Noisy breathing (sound of air bubbling through secretions). Visible secretions. A cough that sounds like secretions are in the tube. Restlessness/crying. Increased respiratory rate. Suctioning Instructions Make sure you have at hand all the equipment you need. Suction unit. Catheter (correct size) - new one for each suction. Connecting tubes if needed. Syringe of saline Bowl or bottle of water to clean the catheter. Turn on suction pump and check pressure is correct as instructed. Gently insert catheter into tracheostomy, Ensure thumb is off port of suction catheter. Apply suction, by covering the port with thumb and withdraw catheter. This should only take 5 or 6 seconds. Repeat if necessary but allow child time to settle in-between. Disconnect the catheter from the tubing and dispose of safely. Clear the tubing with the water provided. Attach a new catheter to be ready for next time. Each time you suction it is important to observe the secretions. Have they changed colour? Are they thicker than usual? Are you suctioning more frequently? Unpleasant smell? Tinged with blood? Child may have infection. GP needs to be informed in case child needs antibiotics. Be aware that when a child has a chest infection he / she will require more frequent suctioning. Changing tracheostomy tube In a non-emergency situation leave tube change for 1 hrs after feed as child may vomit when upset. Tracheostomy tubes are usually changed weekly. Prepare equipment Round ended scissors. Two lengths of inch cotton tapes or Velcro tapes. New tube, check correct size and that the tube is intact. A smaller sized tube in case the correct size does not go in. Water based lubricant. Prepare tube, insert introducer, apply a small amount of lubricant on the outer tubing away from end of tube, place tube ready to use. Position child as for tape change, older child can sit up. Hold the tube (one person). Second person cut and remove the dirty tapes and place clean tapes behind childs head. First person holds tube; second person holds the new tube by flanges and positions the tip near the childs neck. Gently remove the old tube following the curve of the tube. Same person firmly and gently slide in the new tube following the curve of the tube so as not to damage the trachea. Remove introducer if used. Hold new tube securely. If child is coughing allow to settle. Check air flow through tube, childs breathing pattern and colour, suction if necessary. Clean the skin around the tube. Tie the tapes. Do not let go of the tube until the tapes are securely tied. Humidification The normal mechanism of warming and humidifying air is removed with a tracheostomy. Therefore most children have a Swedish nose applied to the tracheostomy to give dry humidification. Wet humidification may also be given by using nebulised saline. Nebulising with a tracheostomy? Medication checked and instilled into nebuliser as prescribed. The most important thing to remember is to stand next to the child with the nebuliser near the tracheostomy, to allow the nebulised medication to be given, but NOT to attach the nebuliser to the tracheostomy as this will cause major damage and restrict breathing. How to recognise blocked tube? Childs may be coughing vigorously. Difficulty breathing. Change in colour leading to unconsciousness. Immediate action is required. Try suctioning. If no better. Cut tapes and remove tracheostomy tube. In long standing tracheostomies the tract will be well developed and no immediate action is required. If still no better. Insert new tube same size or if necessary a smaller size. If still no better. Insert a cut off piece of suction catheter to allow some air to pass through, call for help and phone 999. If changing tube has resolved the problem hold tracheostomy tube in place until another person arrives to help. Reassure child and allow to settle. Suction only if necessary. Child stops Breathing Call for help if someone within earshot. Check if child responsive. Turn child onto back on firm flat surface. Tilt head back slightly to expose tracheostomy. Is tracheostomy blocked? Attempt suction. Still seems blocked? Attempt to change tube. Look listen feel for breathing. If not breathing, shout for help get someone to dial 999. Commence basic life support immediately. DO NOT LEAVE CHILD ALONE, EVEN IF BREATHING RETURNS TO NORMAL . TRAVEL ABROAD Many of our patients will have a desire to travel abroad during their limited life span. This can present particular problems in terms of carrying medication across borders. There are strict rules laid down by the UK Home Office in relation to which medication can be carried and which requires a special Home Office personal export license. These restrictions not only concern controlled drugs but can affect other types as well. There are also rules in terms of the limit of quantity. Each country visited will also have their own rules and the family must contact the appropriate embassy to find out exactly what these are. The Home Office license is for crossing UK borders only; many countries prohibit the import of diamorphine, morphine or methadone for personal use. It is important to check all these details. To find out more information then contact the Home Office on. DLEU 6th Floor Peel Building Home Office 2 Marsham Street London SW1P 4DF Telephone: 0207 217 8446 Fax: 0207 035 6161 Web: www.drugs.homeoffice.gov.uk HOME VENTILATION Children require long-term non-invasive ventilation for a number of reasons; *Neuro-muscular disease - Duchenne Muscular Dystrophy *Ondine curse - Where the child requires ventilation when asleep *Broncho-pulmonary Dysplasia *Cranio-facial abnormalities *Spinal injuries Levels of ventilatory support required will vary among children. For most children nocturnal ventilation of between 8-10 hours is sufficient. The duration and level of ventilatory support required will be dependent on the childs medical condition. Some may have Continuous Positive Airway Pressure (C.P.A.P) via a facemask or nasal mask whilst asleep, while others may require Positive Pressure Ventilation (P.P.V) with the use of facemask, nasal mask or even tracheostomy over 24 hours. Most of the patients are able to come off ventilation for short periods of time. This should be encouraged as this will help to wean the patient off ventilation for periods of time, this will also help with feeding, communication etc. There are various types of home ventilation support devices and these include the following:- The Breas ventilator The Nippead Ventilator Not all children will require additional oxygen through their ventilator unless they become ill or as a result of disease progression. If additional oxygen is required then this is normally achieved by attaching the oxygen supply directly to the mask or a connector close to the mask. Common Problems; The child may become hot/sticky/sweaty beneath the silicone mask. This can also be due to the humidification requirements. If there is excessive moisture then the humidifier heat can be turned down to reduce moisture. Ensure the childs environment is adequately ventilated and appropriate clothing and bed linen are applied. Pressure marks often appear around the ears as a result of the head harness straps, which need to be tightly tied in order that the mask does not slip, as well as reducing air leaks. It is absolutely vital that the head harness is NOT over tightened. Place some gauze over the childs ears prior to fixing the straps. This will prevent the tapes from moving and will provide more comfort around the ears. The facial mask also has the potential to create pressure sores around the mouth and the bridge of the nose. A DuoDerm dressing placed under the edges of the mask where it appears to be tight will minimise this risk. Pressure sores can also be avoided if the mask is NOT over tightened. Most of the machines are designed to cope with small leaks. The ventilator continues to alarm. If the settings are appropriate and it is correctly connected to the child, there may be water in the patient tubing. Disconnect the small tubing from the ventilator and apply suction to the openings on the ventilator. This will remove any excess water within the system. Reconnect the tubing to the appropriate ventilator openings. Consider changing the whole circuit. If not successful, seek further advice. If ventilator connection becomes unattached, ventilator will alarm. Establish if air leak is due to break in circuit. This needs to be resolved, as ventilator pressures will drop, causing machine to alarm. Replacing the whole circuit usually resolves this problem. The child experiences elements of claustrophobia when the facemask is applied. Consider use of different interface such as a nasal mask if appropriate with the type of ventilation required. All alterations to the ventilator settings must be undertaken by an appropriately trained and qualified professional, i.e. Respiratory Consultant, Respiratory Service Lead Professional, in collaboration with the multi-disciplinary team. Any changes made to the ventilator prescription must be documented. In the event of a power cut, establish whether your ventilator has an inbuilt battery back up or whether it requires a separate battery pack. This should always be fully charged. This battery back up will have approximately 2 hours or longer up to 8 hours of usage, this will depend on the capacity of the battery and the power consumption of the ventilator. For long term power failure alternative arrangements will need to be established e.g. Respiratory services supplying a back up ventilator, informing the Electricity Board to ensure the childs needs become priority, and in the event of the child having Ondine Curse, wake the child up and keep him/her awake until alternative arrangements are in place. In some instances it may be necessary to continue with the manual ventilation of the child via a bag and mask device until alternative arrangements are established. Someone who has been trained and deemed as competent in this task must undertake this. These people will be evident within the childs care package or will be established within the environment in which the child is residing. REFERENCES ABC of Palliative Care pages 23-26 Alder Hey Book of Childrens Doses. Sixth Edition 1994 (with amendments 1996) Alder, S (1990) Taking Children At Their Word Professional Nurse May, 398- 402 British National Formulary 2001 Goldman, A. Care of the Dying Child New York: Oxford University Press 1999 Faull, Carter & Woof, Handbook of Palliative Care, Blackwell Science, 1998 Hasting D. Basing care on research Nursing Times 31/3/93: 89(13); pages 70-76 Hillier, Finlay, Welsh & Miles, The Effective Management of Cancer Pain, Aesculapius Medical Press, 2000 Medicines for Children RCPCH 1999 (Personal communication re draft for Medicine for Children RCPCH edition 2003 from Hain R., Brook L., Jassal S., Ballantine N.) Moody M., Grocott P. Let us extend our knowledge base, Professional Nurse, June 1993: 8(9) pages 586-590 Oxford Textbook of Palliative Medicine Section 9.3.3 pages 513-526 Palliative Care Formulary Twycross, Wilcock and Thorp Paediatric Pain and Symptom Algorithms for Palliative Care Mo Pomietto Price, S (1990) Pain: Its Experience, Assessment and Management in Children Nursing Times 86; 9, 42- 45. Symptom control in dying children. Michael Brady. Care of the Dying Child by Lenore Hill. Symptom management in advanced cancer Twycross pages 267-269 Symptom control and terminal care in children with cancer. Department of Haematology Oncology. The Birmingham Childrens Hospital. (1995) Twycross, Wilcock & Thorp, PCF1 Palliative Care Formulary, Radcliffe Medical Press, 1998 Tutorial in Palliative Medicine- Chapter 16 Nursing care pages 344-350 APPENDIX 1: DONT PANIC, WHERE TO GET HELP Dr Lynda Brook Macmillan Consultant in Paediatric Palliative Care Royal Liverpool Children's Hospital - Alder Hey Eaton Road Liverpool L12 2AP 0151 252 5187 07881 788903 Long range bleep via switchboard (0151 228 4811) HYPERLINK "mailto:Lynda.Brook@RLC.NHS.UK"Lynda.Brook@RLC.NHS.UK Dr Pat Carragher Depute Chief Executive (Medical) Childrens Hospice Association Scotland Canal Court 42 Craiglockhart Avenue Edinburgh EH14 1LT Tel: 0131 444 1900 Tel: 0131 444 4015 DDL F: 0131 444 4001 OR Rachel House Kinross, KY13 8AA Tel: 01577 865777 HYPERLINK "mailto:p.carragher@chas.org.uk"p.carragher@chas.org.uk Dr Finella Craig Paediatric Palliative Care Consultant Great Ormond Street Children's Hospital Symptom Care Team (x8678) Direct line: 020 7829 8678 HYPERLINK "mailto:CraigF@gosh.nhs.uk"CraigF@gosh.nhs.uk Dr Richard Hain LATCH Senior Lecturer and Honorary Consultant in Paediatric Palliative Medicine Department of Child Health Cardiff School of Medicine University Hospital of Wales Heath Park Cardiff CF14 4XN Tel: +44 29 2074 3373 Fax: +44 29 2074 4283 HYPERLINK "mailto:HainRD@Cardiff.ac.uk"HainRD@Cardiff.ac.uk Dr Satbir Singh Jassal Medical Director Rainbows Children's Hospice Lark Rise Loughborough Leicestershire LE11 2HS Tel 01509 638000 Tel 01509 263018 HYPERLINK "mailto:sat@jassal.f9.co.uk"sat@jassal.f9.co.uk Dr Susie Lapwood Lead Doctor Helen & Douglas House 14a Magdalen Road Oxford OX4 1RW Tel: 01865 794749 HYPERLINK "mailto:susie.lapwood@bigfoot.com"susie.lapwood@bigfoot.com Dr Renee McCulloch Paediatric Palliative Care Consultant Great Ormond Street Children's Hospital Symptom Care Team (x8678) Direct line: 020 7829 8678 HYPERLINK "mailto:mcculr@gosh.nhs.uk"mcculr@gosh.nhs.uk Dr Mike Miller Consultant in Paediatric Palliative Medicine Martin House Grove Road Clifford Wetherby LS23 6TX Tel: 01937 845 045 Mobile: 07802448890 HYPERLINK "mailto:mmiller@martinhouse.org.uk"mmiller@martinhouse.org.uk Organisations ACT: The Association of Childrens Palliative Care Orchard House, Orchard Lane Bristol, BS1 5DT United Kingdom Tel +44(0)117 922 1556 Fax +44(0)117 930 4707 HYPERLINK "http://www.act.org.uk"http://www.act.org.uk The Association of Children's Hospices First Floor Canningford House 38 Victoria Street Bristol BS1 6BY Tel: 0117 989 7820 Fax: 0117 929 1999 HYPERLINK "http://www.childhospice.org.uk"http://www.childhospice.org.uk BSPPM: British Society of Paediatric Palliative Medicine Chairman Dr Richard Hain Secretary Dr Finella Craig Association of Childrens Hospice Doctors Chairman Dr Mike Miller Secretary Dr Pat Carragher Diploma in Paediatric Palliative Medicine HYPERLINK "mailto:Dippallmed@velindre-tr.wales.nhs.uk"Dippallmed@velindre-tr.wales.nhs.uk Palliative Drugs.Com (Website hosts the latest version of the Palliative Care Formulary, as well as an active bulletin board for drug-related questions). www.palliativedrugs.com Medical resources: paper-based Care of the Dying Child (2nd edition): Ann Goldman A Guide to Symptom Relief in Palliative Care (5th edition): Claud Regnard 2003 (includes a bit of paediatric content from Justin and Susie). User friendly and practical. Oxford Handbook of Palliative Care: Max Watson et al (2005): a wealth of resources in a small space, including a useful paediatric section. Medicines for Children: 3rd edition RCPCH 2006 BNF for Children 2007 (and of course the standard BNF). Palliative Care Guidelines 2006: Max Watson et al. This was the precursor to the Oxford Handbook. It was produced for the SW London Cancer network, has both adult and paediatric sections, and copies are available very cheaply from Princess Alice Hospice, Esher, Surrey, and from the handbook website (HYPERLINK "http://www.greenbox.net/palliative"www.greenbox.net/palliative; 0870 163 0073) Oxford Textbook of Palliative Medicine (3nd edition) Doyle et al 2005 Oxford Textbook of Palliative Care for Children: Goldman, Hain, Liben (Jan 06) Symptom Management in Advanced Cancer: Twycross. Palliative Care Formulary: Twycross (same as is available on line through Palliative Drugs site): 3rd edition Oct 07. Medical resources on line a) child-specific: HYPERLINK "http://www.act.org.uk/"http://www.act.org.uk/ - Association for Children with Life Threatening Conditions. Go to the downloads and other resources option for the useful Rainbows Symptom Control Manual (2006). This site also hosts PaedPalCare (an electronic listserve to post and respond to queries on line) and PaedPalLit (free electronic access to a quarterly-ish roundup of relevant journal abstracts). HYPERLINK "http://www.childhospice.org.uk/"http://www.childhospice.org.uk/ - Association of Childrens Hospices (UK). HYPERLINK "http://www.cnpcc.ca/"http://www.cnpcc.ca/ : Canadian paediatric palliative care, with useful links and resources. HYPERLINK "http://www.gosh.nhs.uk/clinical_information/"http://www.gosh.nhs.uk/clinical_information/ Great Ormond Street Hospital website: useful for clinical guidelines and patient information. b) other sites relevant for palliative care: HYPERLINK "http://www.palliativedrugs.com/"http://www.palliativedrugs.com/ Excellent Palliative drugs website and bulletin board. Very active and helpful international palliative medicine community: post a query here and you should get a useful answer within the day. Also hosts the electronic version of Palliative Care Formulary (Palliative version of the BNF, which includes syringe driver compatibility charts etc), and a RAG section with lots of useful guidelines and protocols from elsewhere. HYPERLINK "http://book.pallcare.info/"http://book.pallcare.info/ : A useful UK site, including the Palliative Care Matters handbook. HYPERLINK "http://www.palliative.info/"http://www.palliative.info/ : Canadian palliative care website with a lot of useful links and protocols. HYPERLINK "http://www.palliative-medicine.org/"http://www.palliative-medicine.org/ Association for Palliative Medicine HYPERLINK "http://www.helpthehospices.org.uk/education/index.asp"http://www.helpthehospices.org.uk/education/index.asp Help the Hospices site is useful in particular the education section has a very full listing of courses available, and the e-learning section has helpful (if basic) brief modules based on the CLIP programme. For information regarding specific diseases: HYPERLINK "http://www.rarediseases.org/search/rdblist.html"http://www.rarediseases.org/search/rdblist.html Rare diseases database - great for looking up rare syndromes. HYPERLINK "http://www.ninds.nih.gov/disorders/disorder_index.htm" \l "F"http://www.ninds.nih.gov/disorders/disorder_index.htm#F National Institute for Neurological diseases and Stroke again a good disease database for medical information (US site). HYPERLINK "http://www.cafamily.org.uk/home.html"http://www.cafamily.org.uk/home.html Contact a Family site useful disease information for families etc and disease-based self help groups. APPENDIX 2: Protocol for Subcutaneous Drug Administration Aim Safe, effective administration of drugs for palliative care via subcutaneous route. Checking procedure prior to setting up pump General points: 1). Ensure that the child and parents/carers have been prepared. The aims of the syringe driver, the drugs to be administered, the siting of the butterfly, appearance and sounds from the driver should all be explained to the child and carers by the doctor, with the nurse present if possible. The child and carers should be given the opportunity to ask any questions, anxieties should be acknowledged and reassurance given where appropriate. 2). The drugs to be administered, including the Diluent, should be checked by two nurses of RSCN or RNCB level who have successfully completed an assessment in the use of Graseby Pumps No. MS16 and MS26 (or other models as appropriate) with attendance at annual mandatory Graseby Pump training sessions. 3). Check that the following details on the drug chart are correct prior to setting up equipment and check against childs records: -Date -Time -Childs name -Childs date of birth -Weight in kg 4). Check that the prescription is rewritten every 24 hours by the doctor and signed. Drugs: 1). Check that the dosage is appropriate by comparison with previous levels of oral medication or by comparison with the preceding 24 hours dosage administered via the syringe driver. Refer to pharmacy literature and check with prescribing doctor if in doubt. As a general rule, on commencement of the syringe driver, the dosage of diamorphine over the first 24 hours equates to one third of the previously required total daily dosage of oral morphine, e.g. 20mg diamorphine is equivalent to 60mg oral morphine in the preceding 24 hour period. The maximum recommended dose of diamorphine when used as the sole agent in a syringe driver should not exceed 400mg/ml although such levels are unlikely to be used in a paediatric setting. 2). If more than one drug is to be used check compatibility by reference to Table 20. Where possible, the number of drugs used should be kept to a minimum, usually no more than two or three. 3). Check Diluent suitability. Water for injection is the preferred Diluent for most drugs except non-steroidal anti-inflammatory drugs, which mix better with 0.9% saline. Dilute diamorphine prior to mixing with other drugs. Do not use 0.9% saline to dilute cyclizine because of the high risk of precipitation. Instructions for use of Graseby Syringe Drivers 1). Assemble equipment: Syringe driver Battery Luer-Lok syringe usually 10 or 20ml Giving set Fine-gauge butterfly Clean dressing OpSite/Tegaderm Diluent Drugs prescribed 2). Insert correct sized battery alarm will sound for a few seconds. 3). Press start/boost button. Motor will run for a short while as safety circuits are checked. 4). Release start button. 5). Set the rate of delivery. This is calculated as: Length of infusion volume Delivery time For the MS16 pump, the setting is in mm/hour. Therefore, if the infusion volume is 48mm, over 24 hours the rate will be 48mm / 24 hours = 2mm/hour.  Rate dial set at For the MS26 pump the setting is in mm/day. Therefore, if the infusion volume is 48mm, over 24hours the rate will be 48mm/day.  Rate dial set at 6). Draw up prescribed amount of medication in a 10ml Luer-Lok syringe and dilute with sterile water for injection. If using diamorphine, draw this up first by dissolving the contents of the vial in a known amount of sterile water for injection and discarding any excess amount of drug if necessary, i.e. calculate the correct volume of dissolved diamorphine required to obtain the dose required. (Diamorphine is available in 5, 10, 30 and 100mg vials). Once all of the required drugs have been drawn up, make the volume up to the correct amount with sterile water for injection. The total volume in the syringe is usually 8-9ml which gives a volume infusion length of 48mm. In calculating the total volume, sufficient water needs to be drawn up to allow for priming of the giving set i.e. filling the whole line including Luer connectors. For most sets this dead space accounts for 0.5-1ml. 7). Site butterfly - the reader should refer to the protocol for insertion of subcutaneous butterfly needle. 8). Start driver by pressing start/boost button. The light will flash every 20-25 seconds. Note that the driver can only be switched off by removing the battery. 9). Protect mixture from light and apparatus from accidental damage by using a holster or carry case. Care of the infusion 1). Check at intervals that the device is functioning correctly, i.e. the light flashes at regular intervals and those connections have not come loose. 2). Check that the child remains comfortable and has an adequate degree of symptom control and an acceptable level of side effects. For breakthrough symptoms the following rules should apply: For breakthrough pain the stat dose of diamorphine is the equivalent 4 hourly dose i.e. 1/6th the total diamorphine dose over 24hours. Do not alter the rate of the syringe driver once set up. This makes it difficult to calculate the dose of drug that has been administered and can potentially lead to excessive doses of one or more of the syringe driver constituents being given. Either: administer additional drugs orally or via bolus subcutaneous, intramuscular or other appropriate route, Or: set up a new syringe driver containing an adjusted dose of drugs. Similarly, use of the boost button is not recommended on more than an occasional basis. 3). Check the butterfly site for signs of infection or inflammation. Change the position of the butterfly each time the butterfly is replaced. 4). Check for cloudiness or discolouration of the infusion at regular intervals (indication of degradation of the drug or precipitation). If this occurs, discard and replace the infusion immediately. Table 26: The compatibility of drugs with OxyNorm injection DrugCompatible with OxyNorm injectionDexamethasoneYesHaloperidolYesHyoscine butylbromideYesHyoscine hydrobromideYesLevomepromazineYesMetoclopramideYesMidazolamYesCyclizineIncompatible in concentrations >3mg/ml of cyclizine (i.e. 30mg in standard 10ml syringe). Use water for injection as diluent.ProchlorperazineNO Table 27: The compatibility of drugs combined in a syringe for s.c. infusion Diamorphine Metoclopramide Haloperidol Cyclizine Methotrimeprazine Midazolam Hyoscine Hyoscine Dexamethasone Hydrobr. Butylbr. Diamorphine c3 c2 c1 ++stable at any ++stable at ++stable ++stable c ++ ++ ++ concentration of any concen- at any at any either drug tration of conc. of conc. of either drug either drug either drug Metoclopramide c3 n p n + ++ n ++ ++ Haloperidol c2 n + n ++ + + p ++ Cyclizine c1 p + + c + ++ p ++ Methotrimeprazine ++ n n + ++ + + p Midazolam ++ + ++ c ++ + + p Hyoscine ++ ++ + + + + n Hydrobromide Hyoscine ++ n + ++ + + n Butylbromide Dexamethasone c ++ p p p p ++ compatible at therapeutic concentrations-some published evidence + compatible at therapeutic concentrations-common usage but no published evidence c=caution at higher concentrations p=likely to precipitate n=generally not a clinically useful combination (same group of drug or counteracting effects) 1=stable up to diamorphine up to 20mg/ml + cyclizine up to 20mg/ml 2=stable up to diamorphine up to 10mg/ml + haloperidol up to 1mg/ml 3=stable up to diamorphine up to 25mg/ml + metoclopramide up to 5mg/ml (Adapted from Faull, Carter and Woof, Handbook of Palliative Care, Blackwell Science, 1998). NAME AGE D.O.B. WT SYRINGE SIZE BD- TOTAL VOLUME IN SYRINGE DILUTENT DATETIME STARTEDDRUG-PRESCRIPTIONTOTAL DOSE IN SYRINGERATE MM/24HRRATE VARIATIONS ALLOWEDDR SIGNCHECKED TIMERATE: MM/24HRHOURLY INFUSION MM/HR COMPLETEDSITE CHECKRESPIRATION RATEPAIN ASSESSMENTSEDATIVE EFFECTSUCTIONINGPOSITION CHANGEBOOSTS GIVEN     PAGE 5 PAGE 45 Basic Symptom Control in Paediatric Palliative Care The Rainbows Childrens Hospice Guidelines The Rainbows Childrens Hospice - 7th Edition 2008 GRASEBY M26 SUBCUTANEOUS INFUSION CHART  PAIN = 0 = 3 = 1 = 4 = 2 = 5SEDATIVE EFFECTS - UNCONSCIOUS = 1 - ASLEEP/ROUSABLE = 2 - AWAKE/COMFORTABLE = 3 - UPSET = 4SITE CHECK - CLEAN/ NO REDNESS = 1 - TRACKING/ WARM = 2 - BLOOD/ INFLAMMATION = 3 - INFILTRATION = 4RESPIRATORY PATTERN TACHYPNOEA = T WHEEZING = W DYSPNOEA = D CHEYNE STOKES = C VOMITING CENTRE MEDULLA OBLONGATA CORTEX EPILEPTIC DISCHARGE ANXIETY PAIN SMELL SIGHT CEREBELLUM SOLITARY TRACT NUCLEUS CHEMORECEPTOR TRIGGER ZONE RAISED INTRACRAINAL PRESSURE VESTIBULAR CENTER MOVEMENT TRAVEL VAGAL SYMPATHETIC GLOSSOPHARYNGEAL TRIGEMINAL G.I.T. COUGH CYTOTOXIC DRUS RADIATION DRUGS URAEMIA HYPERCALCAEMIA TUMOUR BLOCKED SHUNT Simple Analgesia Weak Opioids Strong Opioids Increasing Pain Intensity Diagram of the WHO Pain Ladder 0 2 4 8 =2 U I J m } @Ap=żŞńtŞib[Rh96CJaJ h9>*CJ h95CJh95CJ\aJh9B*CJaJnH phtH h9CJaJnH tH h95B*CJaJph"h95B*CJaJnH phtH h95>*CJ\aJh9>*CJaJh95CJaJnH tH h95CJaJmH sH h95CJaJ h9CJh9CJaJ h9CJ0h9 !.>?@kl}~$a$ 2 3 E T U E J $r^`ra$7$8$H$$a$ S ! m KZAz9p$O^Oa$ $O^O`a$7$8$H$^`7$8$H$p7$8$H$^p`$a$p>lma@fnia n  n $a$dh@&=>mn567?@A[Яtjwh9U#jh9UmHnHuj}h9U%h9CJOJQJaJmHnHtH u#jh9UmHnHujh9UmHnHuh9mHnHuh90JmHnHuh9jh9U h9CJh9CJaJ'[\]^_`ab~˸˴˞ӌ˸˴˞o˸˴d˞jeh9U#jh9UmHnHujkh9U#jh9UmHnHuh90JmHnHujqh9Uh9%h9CJOJQJaJmHnHtH ujh9Uh9mHnHujh9UmHnHu#jh9UmHnHu'9:;=>?@A]^_def̵̵̹̟̹̟p̵̹#jh9UmHnHujYh9U#jh9UmHnHuh90JmHnHuj_h9Uh9%h9CJOJQJaJmHnHtH ujh9U#jh9UmHnHujh9UmHnHuh9mHnHu'9:;defֵ잓tijG h9U#jh9UmHnHuh90J\mHnHujMh9Uh9%h9CJOJQJaJmHnHtH u#jh9UmHnHujh9UmHnHuh9mHnHuh90JmHnHujh9UjSh9U"  CDE_`acdefg˸˴˞ӌ˸˴˞o˸˴d˞j5 h9U#j h9UmHnHuj; h9U#j h9UmHnHuh90JmHnHujA h9Uh9%h9CJOJQJaJmHnHtH ujh9Uh9mHnHujh9UmHnHu#j h9UmHnHu' %&'KLMghiklmno̵̵̹̟̹̟p̵̹#jh9UmHnHuj)h9U#j h9UmHnHuh90JmHnHuj/ h9Uh9%h9CJOJQJaJmHnHtH ujh9U#j h9UmHnHujh9UmHnHuh9mHnHu'   /01FGHbcdfghijֵ잓ցvd#jh9UmHnHujh9U#jh9UmHnHujh9Uh9%h9CJOJQJaJmHnHtH u#jh9UmHnHujh9UmHnHuh9mHnHuh90JmHnHujh9Uj#h9U'    -./>?@Z[\^_`ab~ʿʿvʿd#jh9UmHnHujh9U#jh9UmHnHuj h9U#jh9UmHnHujh9UmHnHuh9mHnHuh90JmHnHujh9Uh9jh9U%h9CJOJQJaJmHnHtH u'234MNOijkmnopqǼޱǔޱwjh90J\mHnHujh9U#jvh9UmHnHujh9U#j|h9UmHnHuh90JmHnHujh9Uh9%h9CJOJQJaJmHnHtH ujh9Ujh9UmHnHuh9mHnHu(ap YHD"l _ >!!!("v"" n  n  n     *+,678RSTVWXYZv˸˴˜ӊ˸˴tb˸˴#jdh9UmHnHuh90JmHnHujh9U#jjh9UmHnHuh90J\mHnHujh9Uh9%h9CJOJQJaJmHnHtH ujh9Uh9mHnHujh9UmHnHu#jph9UmHnHu$vwx%&'ABCEFGֵ잓ցvd#jRh9UmHnHujh9U#jXh9UmHnHujh9Uh9%h9CJOJQJaJmHnHtH u#j^h9UmHnHujh9UmHnHuh9mHnHuh90JmHnHujh9Ujh9U'GHIefg!"#=>?ʿʿvʿd#j@h9UmHnHujh9U#jFh9UmHnHujh9U#jLh9UmHnHujh9UmHnHuh9mHnHuh90JmHnHujh9Uh9jh9U%h9CJOJQJaJmHnHtH u'?ABCDEabcopqǼޱǔޱwޱj!h9U#j4!h9UmHnHuj h9U#j: h9UmHnHuh90JmHnHujh9Uh9%h9CJOJQJaJmHnHtH ujh9Ujh9UmHnHuh9mHnHu( !"#?@AIJKefgijklm˸˴˞ӌ˸˴˞o˸˴d˞j$h9U#j"$h9UmHnHuj#h9U#j(#h9UmHnHuh90JmHnHuj"h9Uh9%h9CJOJQJaJmHnHtH ujh9Uh9mHnHujh9UmHnHu#j."h9UmHnHu'    + , - < = > X Y Z \ ] ^ _ ` | } ~ ̵̵̹̟̹uc̹#j'h9UmHnHuh90J\mHnHuj&h9U#j&h9UmHnHuh90JmHnHuj%h9Uh9%h9CJOJQJaJmHnHtH ujh9U#j%h9UmHnHujh9UmHnHuh9mHnHu& !!!!!!7!8!9!;!!?![!\!]!g!h!i!!!!!!Ӳӂwe#j)h9UmHnHuj)h9U#j)h9UmHnHuj(h9U%h9CJOJQJaJmHnHtH u#j (h9UmHnHujh9UmHnHuh9mHnHuh90JmHnHujh9Uj'h9Uh9'!!!!!!!!!!!!!!!!!!!!!"""!"""#"%"&"'"(")"E"F"G"S"T"U"o"p"ʿʿvʿd#j,h9UmHnHujo,h9U#j+h9UmHnHuju+h9U#j*h9UmHnHujh9UmHnHuh9mHnHuh90JmHnHuj{*h9Uh9%h9CJOJQJaJmHnHtH ujh9U'p"q"s"t"u"v"w"""""""""""""""""""""### # # # ##*#+#,#4#5#6#P#ƻݰƓݰvݰj]/h9U#j.h9UmHnHujc.h9U#j-h9UmHnHuh90JmHnHuji-h9Uh9%h9CJOJQJaJmHnHtH ujh9Uh9mHnHujh9UmHnHu)" #W###F$$$?%%%/&~&&'a''(N((7))D*F*G*H*I*J*K* n  n P#Q#R#T#U#V#W#X#t#u#v##########################$$$#$˸˴˞ӌ˸˴˞o˸˴d˞jK2h9U#j1h9UmHnHujQ1h9U#j0h9UmHnHuh90JmHnHujW0h9Uh9%h9CJOJQJaJmHnHtH ujh9Uh9mHnHujh9UmHnHu#j/h9UmHnHu'#$$$%$?$@$A$C$D$E$F$G$c$d$e$q$r$s$$$$$$$$$$$$$$$$$$$$$$$$̵̵̹̟̹̟p̵̹#j4h9UmHnHuj?4h9U#j3h9UmHnHuh90JmHnHujE3h9Uh9%h9CJOJQJaJmHnHtH ujh9U#j2h9UmHnHujh9UmHnHuh9mHnHu'$%%%%%8%9%:%<%=%>%?%@%\%]%^%u%v%w%%%%%%%%%%%%%%%%%%%%%ֵ잓ցvd#j7h9UmHnHuj-7h9U#j6h9UmHnHuj36h9Uh9%h9CJOJQJaJmHnHtH u#j5h9UmHnHujh9UmHnHuh9mHnHuh90JmHnHujh9Uj95h9U'%%%%%% & &&(&)&*&,&-&.&/&0&L&M&N&[&\&]&w&x&y&{&|&}&~&&&&&&&&&&&ʿʿvʿd#j:h9UmHnHuj:h9U#j9h9UmHnHuj!9h9U#j8h9UmHnHujh9UmHnHuh9mHnHuh90JmHnHuj'8h9Uh9jh9U%h9CJOJQJaJmHnHtH u'&&&&&&&&&&&&'' ' ' ' '''+','-'>'?'@'Z'['\'^'_'`'a'b'~'''''''Ǽޱǔޱwޱj =h9U#j<h9UmHnHuj<h9U#j;h9UmHnHuh90JmHnHuj;h9Uh9%h9CJOJQJaJmHnHtH ujh9Ujh9UmHnHuh9mHnHu(''''''''''''''''''((((( (!(+(,(-(G(H(I(K(L(M(N(O(k(˸˴˜ӊ˸˴tb˸˴#jz?h9UmHnHuh90JmHnHuj>h9U#j>h9UmHnHuh90J\mHnHuj>h9Uh9%h9CJOJQJaJmHnHtH ujh9Uh9mHnHujh9UmHnHu#j=h9UmHnHu$k(l(m((((((((((((((()))/)0)1)4)5)6)7)8)T)U)V)))))Գ윑tijAh9U#jnAh9UmHnHuh90JmHnHuj@h9Uh9%h9CJOJQJaJmHnHtH u#jt@h9UmHnHujh9UmHnHuh9mHnHuh90J\mHnHujh9Uj?h9U")))))))))))) *!*"*<*=*>*A*B*C*D*E*z*|* , ,3,4,G,H,DDDDEEE˸˴˞˸˴z˴t˴ke_e h9CJ h9CJh95CJ\ h90J h9H*#jbCh9UmHnHuh90J\mHnHuh90JmHnHujBh9Uh9%h9CJOJQJaJmHnHtH ujh9Uh9mHnHujh9UmHnHu#jhBh9UmHnHu%K*L*M*N*O*P*Q*R*S*T*U*V*W*X*Y*Z*[*\*]*^*_*`*i*j*L,-U.V.W.`$a$W.X.Y.Z.[.\.].^._.`.a.b.c.d.e.f.g.h.i.j.k.l.m.n.o.p.q.r.s.t.t.u.v...24499,;-;<<<======> >>l@^ & F h88^8``$a$l@m@n@v@w@AAuAAA~DDDDDDDD $$Ifa$$If`$a$DDDDDEEE`ZZZZZZ$IfkdC$$Ifl4\J yK 2/ 044 lalf4EE"E'E9EAE:4444$IfkdD$$Ifl4ֈJ yK 2044 lalf4AE\E]EgEvE}EEEEGkdE$$Ifl4rJ yK 25044 lalf4$IfE\E]EE}K~KKKKKKKKLLMMMi_~_^`````kaza bb~bb`cacccddLeUeeepffqgrgggggnipijkk m1mYnnrrrrrrrsss_s`ssssss h95>* h96] h96h95>*CJ\ h9CJh95CJ\ h9>*h9 h9CJJEEEEE:83-`$a$kdF$$Ifl4ֈJ yK 2044 lalf4EG"HH"IUIIYKZK[K\K}K~KKKKKK $$Ifa$$If` & FKKKKKKK`ZZZZZ$IfkdG$$Ifl4\ {K   044 lalf4KKL LLLLMGG>>G $$Ifa$$IfkdSH$$Ifl4r {K  044 lalf4LL$L*CJ\ h9CJh95CJ\ h95>*h95>*CJ\h95CJ\h9 h9CJh95>*CJIttttt t$If t!t"t)t'!!$Ifkd}[$$Ifl4Y֞3  I $n~044 la{f4)t0t1t3t>t?t$If?t@tAtUt'!!$Ifkd{\$$Ifl4Y֞3  I $n~044 la{f4UtZtdtmttt|t}t$If}t~ttt'!!$Ifkdy]$$Ifl4F֞3  I $n~044 la{f4tttttt$Iftttt'!!$Ifkdr^$$Ifl4+֞3  I $n~044 la{f4ttttttt$Ifttkdk_$$Ifl4ִ3  I $n~0    44 la{f4tttu u u u uu$Ifuukd`$$Ifl4ִ3  I $n~0    44 la{f4uuu'u2u5u7u8u\u$If\u]ukda$$Ifl4ִ3  I $n~0    44 la{f4]u^u_ubueufuguhuiu$Ifiujukdb$$Ifl4ִ3  I $n~0    44 la{f4juyuuuuuuuu$Ifuuuu'!!$Ifkdc$$Ifl4֞3  I $n~044 la{f4uuuuuuv$Ifvvkdd$$Ifl4ִ3  I $n~0    44 la{f4vvvv%v&v'v(v)v$If)v*vkde$$Ifl4ִ3  I $n~0    44 la{f4*v9v:v?vQvavlvqvsvtvuv$If uvvvvv'!!$Ifkdg$$Ifl4֞3  I $n~044 la{f4vvvvvvvvvvv$If $$Ifa$ vvvw'!!$Ifkdh$$Ifl4?֞3  I $n~044 la{f4wwhwswtwuw$If $$Ifa$uwvwwwxwyw'%%%kdi$$Ifl4֞3  I $n~044 la{f4ywzw|w}www1x3x*CJ h9CJ h9CJh95CJ\h95>*\h9\mH sH j ph9UjJJ h9UVjh9U h9\h9 h95>*A/̓ރ/OP߆JK]emu & F$a$ & F `u͉׉'DیabȒ)*pA & FCDEFGHIJKLMNOPQSz| $$Ifa$$IfϘИ`ZZZZZ$Ifkd#}$$Ifl4\ f Y  n P044 lalf4Иј $MGGGGAG$If$Ifkd}$$Ifl4lr f Y  nP044 lalf4$+67\fqxGA$Ifkd~$$Ifl4r f Y  nP044 lalf4$IfxGkd$$Ifl4r f Y  nP044 lalf4$IfGA$Ifkd$$Ifl4r f Y  nP044 lalf4$IfÙڙGkd$$Ifl4r f Y  nP044 lalf4$If4hijoyGkd$$Ifl4r f Y  nP044 lalf4$If֚MGG>>GG $$Ifa$$Ifkdw$$Ifl4r f Y  nP044 lalf4֚ךؚٚ`ZZQQZ $$Ifa$$IfkdW$$Ifl4%\ f Y  n P044 lalf4 MGG>G $$Ifa$$Ifkd9$$Ifl4$r f7 Y  nP044 lalf4 !*/:AHJ`ZZZZZZ$Ifkd1$$Ifl4A\ f Y  n P044 lalf4!/:@AJ_WnoptRS%®Aٴڴոָ()56:;<STU]+-./0=>fg7:ӔӔ h9PJh9mH sH  h95\ h9aJh95>*CJ\aJh96CJaJh9CJOJ^J h9< h9<PJ h95>* h9\h9 h9CJh95>*CJ\ h9CJ:JKLMNOPQRKIIIIIIIkd$$Ifl4]r f K  nB044 lalf4RSTUVWXYZ[\]^_*Wh & FG$a$Ɲǝ8!VWѠ>opqrstJz & FI & FJ & FHz7QRS£ãģghզXŨLʩ˩ܩ./@V & FL & FK & FIV{Y'=$%®Aj & FN & FO$a$h^h & FM & FL sҰ7-aڴ۴ܴ & FQ & FT & FP & FNܴC|̵͵NOvڷuԸոָ & FQ & FR & FSָ56;<GTVWXYZ[\]^jrz{z{|һ & FV & FU-QRn=ABv)/,-/0>? & FX & FY & FW & FV?Xghi 89:;<=>?@ABCDEFGHIJK & FV & FX:=>@ACDEFJKLNpqrpqHI2Lje{05/1Lӹ h95>* h9>* h95\h95>*CJ\h95>*CJ\ h9CJ h9CJh95CJ\h95>*\ h9PJ h9< h9<PJh9@KLMNOPQRSTUVWXYZ[\]^_`abcst:$a$i ,K $$Ifa$$If KLMNbpq`ZZZZZ$Ifkd$$Ifl4\3 y 044 laf4qr|MGG>G $$Ifa$$Ifkd$$Ifl4r3 yVf044 laf4`ZKZKKKK$5*&P#$/Ifb$$Ifkd$$Ifl41\3 y 044 laf4#+pqr8kdf$$Ifl4r3 y^^044 laf4$If$5*&P#$/Ifb$rZkd3$$Ifl4\3 y 044 laf4$If`ZZZZZZ$Ifkd$$Ifl4\3 y 044 laf4 !MKKKKKKKkd$$Ifl40r3 yVf044 laf4!"#$%&'IJ23MNV/ & FE$a$/0[\LMx'~^_W*8_X`$+1'Vw*+8/OPQSuvw;<{|<=_joyӾh95>*CJ\ h9\ h9CJ h9CJh95CJ\h95>*\ h95>* h9>*h9 h95KWX|}2STv4_$a$\v!:UVxy!">h^h^>JVWmno*Jabp^p$a$$a$h^h(QYu/?DR` & F  & F! j ^j ` %1PQROkd$$Ifl4\3 y 044 laf4 $$Ifa$$If RSguvwGkdk$$Ifl4r3 y2044 laf4$IfAkdP$$Ifl4r3 y2044 laf4$If$If  ;<Akd+$$Ifl4Gr3 y2044 laf4$If$If<GL]nv{|Gkd$$Ifl4ar3 y2044 laf4$IfZkd$$Ifl4\3 y 044 laf4$If <=LQ_Gkd$$Ifl4#r3 y2044 laf4$If_joy~A?kd$$Ifl4"r3 y2044 laf4$If$Ify*=>@u*+#2h!#;Z@a &    &'(gh h9CJh95CJ\h95>*\ h9\h95CJaJ h9H* h956>*B*CJaJph h95jh9Ujdh9Uh95>*CJaJh95>*CJ aJ h9\aJ h9>*h9 h9CJ4K)*+=>@AGw@ & F'$a$$a$t+"#12-O & F+ & F* & F) & F( & F'hi55j5]p[ h^`h 4 h^`h & F+`U}:;Z[?@a  & Z        g h^h$a$ & F,g h   cdnoUbc$If`h^h&Qkd$$Ifl4\ Pt A044 laf4$If $$Ifa$ &'(38ZbgGkdʶ$$Ifl4r PtA044 laf4$Ifghpuv~MGGGGG$Ifkd$$Ifl4r PtA044 laf4h67KXno!!((((((((((()%))),)-)/)9)>)A)B)D)Q)V)Y)Z)~)))))... ////3/4/5/C/M/U/g/ſh95>*\h95>*CJ h9CJh95CJ\h95CJ\ h95>*h95>*CJ\ h9\h95>*CJh9 h9CJDMGGGGGGG$Ifkd$$Ifl4r PtA044 laf46MGGGGGG$Ifkdw$$Ifl4r PtA044 laf467FKX`anMGGGGGG$IfkdM$$Ifl4r PtA044 laf4nopqr|MGGGGG$Ifkd#$$Ifl4r PtA044 laf4MGGGAGG$If$Ifkd$$Ifl4r PtA044 laf4GA???h^hkd$$Ifl4"r PtA044 laf4$IfABI J K L M N $a$N O P Q R S T U V W X Y Z [ \ ] ^ _ ` j k ~!!!!!!2"G"$a$G"c"t"""""#$%x&&&N(O(P(Q(R(S(T(U(V(W(X((( & F ^``((((((((((Qkdǽ$$Ifl4\ f O  n F044 lalf4 $$Ifa$$If (((())%)))GA$Ifkd$$Ifl4r f O  nF044 lalf4$If))*),)-).)/)9)>)?)Gkd$$Ifl4r f O  nF044 lalf4$If?)A)B)C)D)Q)V)W)GA$Ifkdo$$Ifl4r f O  nF044 lalf4$IfW)Y)Z)j)o)w)|)~)GkdY$$Ifl4r f O  nF044 lalf4$If~))))))))MGGAGGG$If$IfkdC$$Ifl4r f O  nF044 lalf4)))))*L,.MHHFF@@`$a$kd$$Ifl4Ar f O  nF044 lalf4........./ $$Ifa$$If ////%/3/4/`ZZZZZ$Ifkd$$Ifl4\ f Q  n F044 lalf44/5/>/C/M/U/c/g/MGGGGGG$Ifkd$$Ifl4r f Q  nF044 lalf4g/h/i/j/t/|/}/~/MGGGGGG$Ifkd$$Ifl4r f Q  nF044 lalf4g/h/j/t/|/~///////////////////00+0,0]011&1(1)1*144 68696S6T66677p7q7778899::;;;;c<m<<<<<<<===3=4=_=`=t=}=h95CJ\h95>*\ h9H*jh9Ujh9U h9CJh95>*CJ h9CJh9L~////////MGGGGGG$Ifkd$$Ifl4r f Q  nF044 lalf4/////////MGGGGGGG$Ifkd$$Ifl4r f Q  nF044 lalf4/////////Gkd$$Ifl4r f Q  nF044 lalf4$If//0000000Gkd_$$Ifl4r f Q  nF044 lalf4$If0+0,0-0.060F0L0]0GkdD$$Ifl4er f Q  nF044 lalf4$If]0^0_0s0t0 11+11MKFKKKKK$a$kd)$$Ifl4r f Q  nF044 lalf411&2R222224444]5^56666 68696>6M6S6 $$Ifa$ & FS6T6`6{66vppp$Ifkd$$Ifl)F3=$j  0    44 la{66667smmm$IfkdG$$Ifl4SF3=$j  0    44 la{f477%7@7p7smmm$Ifkd$$Ifl4F3=$j  0    44 la{f4p7q7777vppp$Ifkd$$Ifl:F3=$j  0    44 la{77778-8b888smmmmmmm$IfkdN$$Ifl4F3=$j  0    44 la{f488889I9z999smmmmmmm$Ifkd$$Ifl4F3=$j  0    44 la{f4999::.:`:::vppppppp$Ifkd$$IflF3=$j  0    44 la{:::::;vpppp$IfkdU$$IflF3=$j  0    44 la{;;.;@;\;;vpppp$Ifkd$$IflJF3=$j  0    44 la{;;;;;c<vpppp$Ifkd$$IflVF3=$j  0    44 la{c<d<e<g<h<j<k<l<m<<<<<vtttttttnthh$If`kdP$$IflFF3=$j  0    44 la{ <<<<<<<<==Qkd$$Ifl4\ f S  n J044 lalf4$If $$Ifa$ ===#=(=)=/=3=Gkd$$Ifl4r f S  nJ044 lalf4$If3=4=5=A=T=_=MGG>G $$Ifa$$Ifkd$$Ifl4r f S  nJ044 lalf4_=`=o=t=}====`ZZZZZZ$Ifkd$$Ifl4\ f S  n J044 lalf4}================> > >>>>>>*>3>5>6>>>>>>>>>>>??(?1?C?D?b?m?r?|???????@@3@4@6@@@D@F@G@I@S@W@Y@Z@\@g@k@m@r@s@@ h9aJh9CJaJh95>*CJ\ h9\h95>*CJh95>*CJh9 h9CJ h9CJJ========MGGGGGG$Ifkda$$Ifl4r f S  nJ044 lalf4========MGGGGGG$IfkdP$$Ifl4r f S  nJ044 lalf4=======>MGGGGGG$Ifkd?$$Ifl4r f S  nJ044 lalf4> > > >>>>>MGGGGGG$Ifkd$$Ifl4_r f S  nJ044 lalf4>>>>*>3>4>5>MGGGGGG$Ifkd$$Ifl4_r f S  nJ044 lalf45>6>B>C>H>m>u>>MGGGGGG$Ifkd$$Ifl4_r f S  nJ044 lalf4>>>>>>>>MGGGGGG$Ifkd$$Ifl4r f S  nJ044 lalf4>>>>>>>>MGGGGGG$Ifkd$$Ifl4r f S  nJ044 lalf4>>>>>>?`ZZZZZ$Ifkd$$Ifl41\ f S  n J044 lalf4???(?C?smmm$Ifkdq$$Ifl41F fS  n0    44 lalf4C?D?S?X?b?m?r?|???smmmgmmmm$If$Ifkd%$$Ifl41F fS  n0    44 lalf4 ??????MGGGG$Ifkd$$Ifl46r f S  nJ044 lalf4???????`ZZZZZ$Ifkd$$Ifl4/\ f S  n J044 lalf4??@@@@@3@MGGAGGG$If$Ifkdy$$Ifl4Br f S  nJ044 lalf43@4@5@6@@@D@E@F@MGGGGGG$IfkdT$$Ifl4r f S  nJ044 lalf4F@G@H@I@S@W@X@Y@MGGGGGG$IfkdC$$Ifl4r f S  nJ044 lalf4Y@Z@[@\@g@k@l@m@MGGGGGG$Ifkd2$$Ifl4r f S  nJ044 lalf4m@n@o@p@q@r@s@@MKFFKAFdh$a$kd!$$Ifl4r f S  nJ044 lalf4@@@@?B@BBBCCCCJJ?QQQQ5R6RSRTRRRRRRsStS]W^WYYYYYkZnZZ[\\\\\dddddffhhhij2j3jCkDkllޯ媥h9CJaJ h9>* h96h956>*aJ h95 h9CJH* h95CJ h95>*h96>*CJaJ h96>*h9h95>*aJ h9CJ h9\aJ>@@@kAAA@BBCCCWDDDE?EEEEFGaIbIJJJ & FBdh & FAdhdhdh@&$dha$JJK!LYNZN[N\N]N^N_N`NzN{N4O5OOOO6PPQ>Q?QQQ $dh$Ifa$hdh^h & FCdhdhQQQQQQQQQ5Rhkd$$IflF t"   t0"6    44 la $dh$Ifa$ 5R6R7RPRQRRR`RaRRthhhhhhh $dh$Ifa$kd$$IflF t"   t0"6    44 laRRRRRRRRRthhhhhhh $dh$Ifa$kdb$$IflF t"   t0"6    44 laRRRRRRRRR=SSTtnnnnnljeeedhdh@&kd$$IflF t"   t0"6    44 la TTTT;UUU)VVVV WW^WsXYYYYYYYYnZoZZZ[ & FDdhdh[F[G[\\\\g]^b_c_aa7c8cccccddddddddddddhdddddddddeecZZZ dh$Ifkd$$IflF     t06    44 la $dh$Ifa$dh ee e e e e"e#e$e=e>eWeXeYeeeeeeee&f'ffffff dh$Iffff g ggggg*g+g* h96>*h95>*CJaJh9>*CJaJh95CJaJh95>*CJaJ h9\aJh9CJaJ h9H*aJ h96aJh96CJaJh95>*aJ h95 h9aJ h96CJh9 h9CJ.TmUmVm`mamjmmmtnnnthh_______ dh$If $dh$Ifa$kd&$$IflF     t06    44 la n=ooooooo"pkppkigbbbdhkd$$IflF     t06    44 la dh$If pqiqrVrWrlrmrr&sssss t tttvvvv$w%wuwwwxdh & FFdhxxx\y]yYzZzhzzzz {!{|||||~~~~~Kdh !"#$45)*ρ & F& hh^h & F%$a$$a$ρ$Rl >?؄ل҅Ӆ$ & F$ hh^ha$$ & F#a$$a$ & F& hh^h҉Ӊ./ȍՍ)*GHh^h$ & F$a$$a$/  )*GHSTӖՖ֖QRwxYZޘߘ  ()+TUΙϙЙљ"#STVϻϻϰϻϻϻϻϻϻϻϻϻϰϻϻh90J5CJaJ h9>* h90Jjh9U h95 h95>*h9jh95>*CJUaJh95>*CJaJh9CJaJh956CJaJASTw*+TЙљUV/013458;$a$$a$V-.18;ߥ)+,-.<ϧܧѨ")תتު NTUst{«ëɫJPszǬ[\bqȽ½½ h95\ h9] h96 h96]jPh9U h95 h9>*h9mH sH h95\mH sH  h90Jjh9Uh9F;<=>?@ABCDEFGHINO*MNWXtŸߟ & F`$a$ߟ ,-01<=./<ΧϧܧШѨ` & F"תتNOt«ëIJs[\qNO` & FNܳEԴ0~ݺmɻ & F & F & F"`{оOѿ@vwHI}*q & F? & F> & F= & F=` & FȽ_aR_P`z5B L}~b#$%'IJKfu ,./FRfg{h95>*CJh95>*CJ\ h9CJ h9CJh95CJ\h95>*\ h96>* h956 h95>* h9>* h95 h9H*h9B!QRIlo$DOP & F & F@` & F?P`uz{45B GI`IJKL}~ $$Ifa$gkd$$Ifl P! t0644 la$If  v $$Ifa$$Ifzkd[$$Ifl0<  t0644 la!x $$Ifa$$Ifxkd$$Ifl0<  t0644 la!",1x $$Ifa$$Ifxkd]$$Ifl0<  t0644 la12@Dx $$Ifa$$Ifxkd$$Ifl0<  t0644 laDE\`x $$Ifa$$Ifxkd[$$Ifl0<  t0644 la`ab$Ifxkd$$Ifl0<  t0644 la $%&';IQkdY$$Ifl4\ f a  n X044 lalf4$If $$Ifa$ IJKWfuGA$Ifkd-$$Ifl4r f a  nX044 lalf4$IfGkd$$Ifl4r f a  nX044 lalf4$If Gkd$$Ifl4r f a  nX044 lalf4$If,-./AFRGA$Ifkd$$Ifl4r f a  nX044 lalf4$IfR[afgv{Gkd$$Ifl4:r f a  nX044 lalf4$If'23VWYd  '.;<JUdeDEefwEFGIklm)*QR#$h95>*\h95>*\ h9CJh95CJ\h95>*CJ\h95>*CJh9 h9CJ h9CJKGkd$$Ifl4r f a  nX044 lalf4$IfGA$Ifkd$$Ifl4r f a  nX044 lalf4$If'VWXYdGkd$$Ifl4r f a  nX044 lalf4$IfdyG> $$Ifa$kd$$Ifl4Lr f a  nX044 lalf4$IfZQ $$Ifa$kd{$$Ifl4\ f a  n X044 lalf4$If*1?YZ`ZZZZZZZZZ$IfkdJ$$Ifl4\ f a  n X044 lalf4 Z  Gkd$$Ifl4r f a  nX044 lalf4$If  '.7;`ZZTTZZ$If$Ifkd$$Ifl4D\ f a  n X044 lalf4;<EJU`dMGGAGG$If$Ifkd$$Ifl4:r f a  nX044 lalf4deot|MGGGGG$Ifkd$$Ifl4*r f a  nX044 lalf4MGGG>>G $$Ifa$$Ifkd$$Ifl4$r f a  nX044 lalf4`ZZQZ $$Ifa$$Ifkd^$$Ifl4\ f a  n X044 lalf49D`ZZZZ$Ifkd($$Ifl4\ f a  n X044 lalf4DEPUae`ZZQZ $$Ifa$$Ifkd$$Ifl4\ f a  n X044 lalf4efrw`ZZZZZ$Ifkd$$Ifl4&\ f a  n X044 lalf4MKKKKEE$Ifkd$$Ifl4<r f a  nX044 lalf4'FGHI]kQkd\$$Ifl4\ f g  n X044 lalf4$If $$Ifa$ klmG> $$Ifa$kd0$$Ifl4r f g  n\044 lalf4$If)`ZZZZZZ$Ifkd$$Ifl41\ f g  n X044 lalf4)*8=?HQ`ZZZZZ$Ifkd$$Ifl4F\ f g  n X044 lalf4QR`eoz~MGGGGGG$Ifkd$$Ifl4r f g  nX044 lalf4MGGGGGGG$Ifkd $$Ifl4r f g  nX044 lalf4!#$.KPGkdZ $$Ifl4r f g  nX044 lalf4$IfP`tuZkd5 $$Ifl4-\ f g  n X044 lalf4$If $tu!+5:ETW./8FGorOP_` ؼصتؼؼأؒ h9>*h9CJaJh95>*aJ h9>*aJh95>*CJaJ h96aJh95>*aJ h95aJh95B*aJph h9aJh95>*\ h9CJh95>*CJ\h9 h9CJ7Gkd $$Ifl4ar f g  nX044 lalf4$IfMGGGGGGG$Ifkd $$Ifl4Zr f g  nX044 lalf4"+5:EJOPT$If TUVMKKKB $$Ifa$kd $$Ifl4r f g  n\044 lalf4$If $$Ifa$ekd$$Ifl4Xhh044 lalf4 kd($$Ifl4ִ S ,h0    44 lalf4 "&*.$If $$Ifa$ ./kd$$Ifl4Jִ S ,h0    44 lalf4/OT\dlt|$If $$Ifa$kd$$Ifl4ִ S ,h0    44 lalf45678FGopqr$a$.$$d%d&d'dNOPQ]^a$$a$$a$$a$rpqOP`aNO7$8$H$$a$$a$$ *a$       l m $a$$a$  n x   Z[\^,6w CDst"*,-/=EGHjh95>*CJ h9CJ h9CJh95CJ\h95>*\h9 h9>*R  '0<[ $$Ifa$$If [\]^r`ZZZZZ$Ifkd$$Ifl4\ f O  n F044 lalf4MGGGGGGG$Ifkd$$Ifl4r f O  nF044 lalf4Gkd$$Ifl4Br f O  nF044 lalf4$If MGG>G $$Ifa$$Ifkd$$Ifl4r f O  nF044 lalf4',6Fwx`ZZZZZZZZZ$Ifkdz$$Ifl4\ f O  n F044 lalf4 MGGGGGG$IfkdD$$Ifl4r f O  nF044 lalf4MGGGGGG$Ifkd3$$Ifl4r f O  nF044 lalf4MGGGGGG$Ifkd"$$Ifl4r f O  nF044 lalf4 MGGGGGG$Ifkd$$Ifl4r f O  nF044 lalf4&+27CMGGGGG$Ifkd$$Ifl4r f O  nF044 lalf4CDNS^sMGG>G $$Ifa$$Ifkd$$Ifl4Dr f O  nF044 lalf4st`ZZTZZZ$If$Ifkd$$Ifl4]\ f O  n F044 lalf4MGGGG>G $$Ifa$$Ifkd$$Ifl4r f O  nF044 lalf4MGGGG>G $$Ifa$$Ifkd$$Ifl4r f O  nF044 lalf4 MGGGGGG$Ifkd$$Ifl4r f O  nF044 lalf4"*+,MGGGGGG$Ifkd$$Ifl4r f O  nF044 lalf4,-./=EFGMGGAGGG$If$Ifkd $$Ifl4r f O  nF044 lalf4GHSXY^jMGGGGG$Ifkd!$$Ifl4r f O  nF044 lalf4jklmnopqrMKKKKKFK$a$kdo"$$Ifl4r f O  nF044 lalf4rstu~&'*+(*  5!6!K!!! "$a$'/+56!K!$%%a%b%c%e%%%%&&t&u&&&&&&'' ''''''''/'1'2''' ( (( ((((())))R0}0~0001111 2 2G2H22233w3x333h96>*CJ] h95h95>*CJ h9CJ h9CJh95CJ\ h9>* h95>*h95>*\h9H ")"S"y"""""!#;#<#{##D$$$$$$$$$$$$$$$$ & F/ & F.$$$$$$$$%%%%.%7%C%b% $$Ifa$$Ifb%c%d%e%y%%%`ZZZZZ$IfkdJ#$$Ifl4\J Y  P044 lalf4%%%%%%&MGG>>G $$Ifa$$Ifkd$$$Ifl4rJ  Y 5P044 lalf4&&&"&B&t&`ZZQZ $$Ifa$$Ifkd%$$Ifl4\J Y  P044 lalf4t&u&v&}&&&`ZZQZ $$Ifa$$Ifkd%$$Ifl4+\J Y  P044 lalf4&&&&&&&'`ZZTZZZ$If$Ifkd&$$Ifl4\J Y  P044 lalf4''' '''''MGGGGGG$Ifkdf'$$Ifl4}rJ  Y 5P044 lalf4''''''/'0'1'MGGGGGG$IfkdU($$Ifl4}rJ  Y 5P044 lalf41'2'g'n''''MGGGGG$IfkdD)$$Ifl4}rJ  Y 5P044 lalf4''''''' (MGG>>GG $$Ifa$$Ifkd3*$$Ifl4#rJ  Y 5P044 lalf4 ( ( (((((`ZZZZZ$Ifkd+$$Ifl4\J Y  P044 lalf4( (+(D(T(b(f((MGGGGGG$Ifkd+$$Ifl4rJ  Y 5P044 lalf4((((((((MGGGGGG$Ifkd,$$Ifl4\rJ  Y 5P044 lalf4((((()))R)MGGGGGGG$Ifkd-$$Ifl4rJ  Y 5P044 lalf4R))))))))GE@@@@$a$kd.$$Ifl4PrJ  Y 5P044 lalf4$If)))))))))))))++2,~,,--%..Q0R0}0~00$Ifh^h & F $a$000000001^kdg/$$Ifl\8 RRSS0644 la$If111=1[11d^^^^$Ifkd/$$Ifl\8 RRSS0644 la11111 2d^^^^$Ifkd0$$Ifl\8 RRSS0644 la 2 22(2F2G2d^^^^$Ifkd,1$$Ifl\8 RRSS0644 laG2H2N2`222d^^^^$Ifkd1$$Ifl\8 RRSS0644 la222223d^^^^$IfkdZ2$$Ifl\8 RRSS0644 la333w3x333333db`ZU````$a$`kd2$$Ifl\8 RRSS0644 la 333333 4!4%4)4b4d4f4g4y4444444444445585:5~55555555556 >>>4>? ? ?(?BBEFFKKK?L@LQLM MPQjQkQQRgVwVpWWXX|YYٻ h95 h9>*jh96UmHnHu h96 h95>* h9aJh9 h9CJjh9CJUmHnHuJ333333 4"4#4$4%4b4e4f4v4x4y444444444444 5 5 5555657585e5~5555555555556 6 6 6 6 6656 & F 56S6g6h6666666$7O7W7X7u77777788*8 & F^ & F^ & F^h^h & F^ & F  & F ^*8E8F8Y8{8888888L9~9999D:E:F:f:::::: & F & F & F^ & F h^h & F^:::;; ;9;i;;;;;;<8<E<<<<<<<=T== & F & F^ & F^ & F^ & F  & F^=============>>>>>>>>> >>>? ^`$a$` & F? ?*?A?d?u?v?z@{@@@ANAfApAAAAAA0BBBBqEEEEE & F0 & F<EFF G GVGGGGGG+HzHHIJJKKKK L?L@LQLLLL & F3 & F4 & F1 & F2LLMM MWMeMMMMMMMM* h95>* h95 h96h9D ]6]7]w]x]y]z]{]|]}]~]]]]]`aaaaa+a* h96]h95B*\phh95>*B*CJaJphh9B*phh9B*phh9, vTvv w-wwxZxxxEyyyhzz { { { {{{{{{{{{ & F & F j  Y p#{{{{{{F{G{H{W{{{{{{{#|f|g|x||||||| }"}7$8$H$$a$$a$$a$"}3}6}C}M}W}i}}}}}~(~C~~~~~~3>Oe{7$8$H$j}}}}}}}C~D~i~j~|~}~~~{|RSyz%&?@BU؁ف#܂݂HՃփ h95>*h9B* mH phsH h95aJmH sH h95B*ph h90J h95h9CJOJQJ^Jh90JmH sH jh9Uh9A '0ARABU{؁#Q7$8$H$Hdu˄̄$a$!"34FGNOVWjk}Ʉʄ˄>h˅̅&')?݆_a)*EFƻܠܳƒh95>*PJ\mH sH h90JmH sH h9H*mH sH h9mH sH h95\mH sH h95>*\mH sH  h90Jh9jh9Uh90J"5B*ph@@@ h95h90J"B*ph@@@9̄ =>h˅()?Ć܆݆0ڇf͈W & FZ$a$Ëlg/0]Us>?lږۖop$a$`$a$Ëċlmgh͎Ύ0[]^UV|} $%stǒȒ/0eflmؔٔbcIJnoۖh96]mH sH h90JmH sH h9jh9Uh95\mH sH h9mH sH PǛԠDEڣۣBDEklٴڴ678%&DEklȶɶDEhijh9Uh95>*CJ\ h95CJ h9CJ h9CJ h95CJh95>*CJ\ h9H*jh9UmHnHu h95>* h9\h9 h9>*?lm#$+2AYhiǛț̜͜gh$^a$$a$hKLӠԠ-9Oqr{ա֡56$a$$^a$$a$$`a$6PQDFYZ[ڣܣpqާߧ$a$ $a$$a$Z[٫J|}EFG$If$a$$a$$a$$Ifxkd3$$Ifl0<  t0644 laˮϮ$Ifxkd4$$Ifl0<  t0644 laϮЮ$Ifxkd4$$Ifl0<  t0644 la$Ifxkd5$$Ifl0<  t0644 la$Ifxkd5$$Ifl0<  t0644 la*.$Ifxkd6$$Ifl0<  t0644 la./9=$Ifxkd6$$Ifl0<  t0644 la=>HƯ$Ifxkd7$$Ifl0<  t0644 laƯǯدۯ$Ifxkd7$$Ifl0<  t0644 laۯܯݯޯ߯$a$xkd7$$Ifl0<  t0644 laBCD̰Ͱ j  Y "&d P  j  Y " &d P  j  Y p#$a$N}ͱѱұӱCDEFefg j  Y p# j  Y p# j  Y "ghٲڲ۲r Nٴڴ7 j  Y p#&d P  j  Y p#78[ҵߵ$If  9r $If j  Y p#]^ kd~8$$Ifl4      ִS}&,(5Sn 3N0          44 lalf4      !"#Ff=Ff:$If#$%&',-./0123456789:;<=>?@A  9r $IfFf@$IfABCDESTUVWXYZ[\]^_`abcdefghi  9r $IfFfyE$Ifijkl  9r $IfFfTL$If¶öĶŶƶǶȶ  9r $IfFf/S$Ifȶɶڶ۶ܶݶ޶߶$If  9r $IfFf Z     $If  9r $IfFf`,-./0123456789:;<=>?@ABCD$If  9r $IfFfgDEPQRSTUVWXYZ[\]^_`abcdefghiFfvu$IfFfniyz{|}~FfQ|$IfFf,$If·ķŷзѷҷ޷߷vwx&'Zk  9r $If$If$a$&`#$·÷ŷƷ̷ͷηϷзҷӷٷڷܷݷ޷uvxkl4ϸ󖍖}vpipT)h95B*CJ OJQJ\^JaJph h9>*CJ h9CJ h9>*CJjh9CJUmHnHuh95\aJh95CJ\h95OJQJ\h95>*CJOJQJ\h95>*CJ\h90JCJmHnHuh90JCJjh90JCJU h90Jjh90JUh9jh9U klϹ  .Qnú޺$If  9r $If$If"456=ca__VVQ_V$a$ $7$8$H$a$kd$$Ifl      @\6 '45T U T U 0      44 laN 456=>?STUnop{|}һӻԻ*+,RSTqrs h95)h95B*CJ OJQJ\^JaJph#h9B*CJ OJQJ^JaJphh9 h9CJ .=>?STU]bhnop{|}ɻһ $7$8$H$a$$a$һӻԻ*+,39HRSTZbqrs $7$8$H$a$$a$szԼռּ$a$ $7$8$H$a$/ 0&P . A!"#$% ,&P . A!"6#$% /&P 0A .!"#$% ntV}wy PNG  IHDR;wwsRGBIDATx^Vspi!3+ٳR$M"HQPҰV%4JEU4Ri}\Z_s>|#͛? 3{2x>xkxg xb(xg { x+&g xb(xg \a|3@<1@< 3[=@< XO~OΣ]G]Udt#Ծ# ֶB[RvGYIKehp[{_~xŁ;CWxIO;rk3}oצÝ^sWNn^?8x&WaoݞK#sQ]j#fXPF#vzW;1E;} 6~gXj2-sgp|\WsʨҹծXmWdWWI l*L|J?sMߟn6,QuO5vC+H&_‘O_}']rdϲCL*}iRsaWXnʞQbTl̞}'veV݀{z3x,H.wlk7xՉ~džƿYgK.:|ɉFX9 [jsbNsͺrhwϪt=pЏ}c${jzsȚ|hsUsapDN:@Μ'1oa䓎HL/ =qm̉YJj޸dOcM{b?=hQY δi)ٹRnǵ/9e컳QpiڬG]cTuْGrZ%X|_rAp{z ^chɲEvO6L9_}<ݸn䑧\]{ lAv[s_&ozA ~3yK@{Ƚx1lxyJ˞;.K= Y|m/wǭĤv>o2_9Z!*O~PUMAydĞ5t{ᕩ7}z65' gG=_ރ@26Ln6t"~wR7yH[=n,%f:ob޶:*WsGsz n0' b`6my8hU2mM-]*ibHӼ: ۚ-/o~p@K篟pݟ;Mo]{rrd[,GN*N?Sܾa)(1`=Hq vzOx-4.oa>43nkT[:B1=+mn~KmrȱyjߗdOaI%[&iM0ȦLvF劘CBᅝ+ :|1pF[fضCA2?ۚc5 Y柑< ۚ-/I\@K篟mB / s+uDaO5 )(c/ W!?)vNn?j;A=s;wa۹nu kF~nۺV`ID6Sh /Hm:Y]; d,dƧ9a 0y`kZ?+6&"8G9$;j;Լ5O!w$8Gbt[?xO1H6JֆNqéI0_UL|F?Is"v<}nkVGGD%d%C{Kf!8%f'~0;)jK>Qe;X  d BlN2Av\Ðwn;3Yd%16DŽJh[k,Umc7Sj衣 涂 ~e:?,M e0цhCrs:qv֯VM^n3Y` ]]8 Iڃyū3*%a9eF!rʠ'@ƬBVW!kܨ=i.sg`;3K]q+/=VDx[cH|F lux 9S@< lk2f@< 3CyY㓊g @ xx#g ='@< 36_ 3G@ {eO*x26nl<|uK;`v< 3@vVnvM3113xvp7 pg Y@< P]x8 3wp۴鷿cl1g hv2E@< -3(<2nƟxg`ϝ+sm|f 30S@<{ P^g 3Ca*^1xpϽ3@g tOUb< 3C{m3g t@ 鞪xxsg =g@<鞁 =U 3@ {,x=1{g`ϝ kY< {b(LT+3;16>xH PWg =wb(sm|f 30S@<{ P^g 3Ca*^1xpϽ3@g tOUb< 3}?Za߼^g 3¹.CNwKWd`Ug`ϝZ9p|f.]ߺJG}"ܛ<>xv<Z^~pA;^wXwޟ =5>5o͜3v'?%=ٳ=G\$ _&~z^~Uy)=og9b_ϼ>V[xټ_z92O'8 x 3 uOC,73{xV|ɅO;K^TlѪG+P\Y탏 1xvruPh9/8wtQaW/5K4򱧇;E +?%<; ]k-Z%S>g_.)7g o2x^os7]5KWͺuƍ~o#m\rˑxnoۅ?Pj/_Ͽo1g:r|F1{5kmN9C:ϿVxv lݿ d|cGϝ;ATV͛_7@IzmQPX"K0v鲟2g͞8\Jɳ/V?=x[:-#1Y+]uVY|*/Gd\Obʞ-+2!O3eg,W< K0}_>SO,T|v>kG=qƍ.X?^rP;p[v=wљHpnXWߚ2u0|,q叿wn%KNx:~fTw,ei=?rc|h+~;4;v^Ͱg;e+~bs"U>p/,\0on 9"sf/M=k/E g_ Gc? gZ$n<^ϏfB=Bxu`}r}JgVdSO8xx,~< _!ڴ鷭 G?<,p)'ݪv_/;b[jx+8[rr'Ps8;X™6lܴvz57lʓy}o5W5Tm<nPaæw?+2ք_^z}FvlS=PXǎ=^y-w W'ph lܴ{aE?sgʞl|Ĉ[:hb $ϓ\~XC}A~ٳY|g#uFA?~\n/k]װ¥ͯX漮G>;,XԸWf˚%*X+(q)]ZGɴW T&^[gmWg ZB̖- дoŧ[~Janx gPh<ß}-Zg銝X 2yO<;tbxɅJ-G5Vp1w~}|3oɨwQN:#f]<2xG8,{,k*|CU*wEO4‘؏D%#J\o/#^ӺׂMߦ%x/k/:C?kvy)oԻ>%?2a[ GNKbINҰ; 9Njתr~b8"_N-‰~ۋ ,7rL?Z'_?W\XS_7P;4R _._s3(7X'O" -aY-^_@)o5f7UB?G9p\pg/(~i':| x4iWWK6$~?|+av')R8~ٳBG=]^OOo@R~)u䏿feS3FKÞe}3e9eY~. C׮ |e?^[D;ƓO(}0_, ajTX Ͼgs8 yv&癧b*E~9_W,<.8DI֬Y`(K)W>qȉ3S'h򟾞Vzx3B VgG3 t=`9f <|PiMH0b̤"G/_X ?,* FeW%(Gl|gq~iݨ5%4@",_ꃏ>SO8ʗ_yڕ?F[\Ḻ㥅߯iK=N 2~9!aq5= M(k"_j"V=[dn*I74|1mݞ?3/w>-˨?;;4 x)ea:g>-{Te;XIxM[|w=Vc/gupGwߟ -~abl8yZߵW٩A>Kko^~v I,OCxC|5X9:ֻF^O җ~uR"\Pk/IE/} B/Sї=:{f`I= s8J_|Fb}[,q toR~+\O3<1<]y]8 $)6!k.B"S2m,\&kШײTV!\!dkiBCCFyqϑs3U,rv?Ok`1qu=K{xCF=?!GW9Ǻͻ>N=WQjBEq8{({Y˞~Fdooޝ|]Xg?|ké r^yə}f4_=@mo)_C:x ا6FVc5~}=,cHYfww,[8g`W@ [U4iV?6_vmHg"ذM\(x<;/-ӏ[ʽtQyt)QP~V'3Pu"G;}u>%d_r)QU J vV)QNB5 ?rM#pn JWu:cju/.qY9>ز+xe\wW?dM_.yi׀?~+$+7 0?*@q)0N<(nysxܓiʼ?vWO~XG&D#7Ek֮yZ;?G8=2_ +q?]K_rYvGbjL >#N9Vrl֬ey+"@_:Yer n.+]Y@)on8`ؒ64[ m+N:M9ky:wk9/=.-qFp5GЖYbJ EAcA*?Ubi`(⁰}o,ݕ]p9gÍ#^Ӯh6LQ P>! -UX<* `dLnxݾōW\TL`Us>% AGZDhj,L9tw^lϤ ArNd[C} 72H_9a.XB;!.o~3 0}}Q/|knn{ZW`Ʀ;[=΃-zoxǣ(ggʳ3>@mnㇽoqʗ?!%3;ۻ!DYуA6v 2ۤzN>p@Ob+*pаq:B-eUv0;޻:K}q#?nbix(97TiXjmi+X y99;m0财ĜCĢ~D~ɲMOBsg +11 nn| /MlKV\5bE" ˜ _z)]M&wEmwUe5I7P 7{PdI˭#lݰ2%k(e_fo)q(k˓2Q 6p#%"ZDEq,ӏc% ~s!Jz~\}M.]3цN"eH[L0_X Aij#X&K/b Q{YN|P0׬[y/MoOW=1*| V+]_:E;cߚ15fˑ5rES38*#gxUЋ}3THK^6kךtj*61h›b#PP3]7ߙW'|ݤ!63@UX9[ ć qnt/[- 7(9=PWϪ 'ӎE#5nK2M$d^'9ER8Ph*8A񂁔x:~=x4qTa?XBy͘=tj'%Z Fx#Gzb4Q^!N 9,V -he1~ҌYf3lMxr,_yrEv D7BH<`ӋH5Oύ`_Fd[3 O6HP=S,y¥.8OǨp 4Q#3{X1DE CNK0/\% Ȧ_$i3kV/s&FY_ %l)ya1'6p5sfg1o1Ia_/&+qTW<R" c+Ё!QTbG.ӫ '5c6Pᠡ!Rm_pAk^ol"qY=˗.Lxh"xN;4 !vwK NHFg j!x/&߹uf8m3f܁P[8hbd7BVgڰ g_R\[ԯԮY35o%n :wMG l4mCJ;;׆g$[Qjݎ~5ѭpQ"k{<뛡O7ǸBQsL{ >/d;uubmf7~/-)H)}Ͻ{K'^;>O6Y^zA0J+ˆCuze띷^(& w]mٶEО-mz>7j<_{X˨bfcD,7ߍ kWCGLсQ&xQO,^+\E֧,o93sۜanԃsdnm]|.G-lmK%y\Y1eoOo+tu~fcx e_H,`7WBqbaV ZdЗÇ`UI,'빋Y`M)=#{?ᇖO4N'T$eJ!1GTS>vun( 8!򎚸^|gڧs:EOǓ8y00'2pо ðٸmg%Ty wb(sot3O9ʡcH@=Gxl .Ԃ@ 'h8$lv9$cgQ !ĞXх|= gY 5IDqD6}Iq[\iYnMpLbY\v/vXgr9ٳ:f ]Jd˖J{&O .c'Zj :2tƙ(ԙ#O06T`wY'W(J3`Nk"1cNm54+bw" Tl@L'a՚.HoF\̜c*ewn;^h;N}/]18̢< ?䔹LQ@zf M9K_|sHetxh/U1es.FyȁT 'ϗ1wDɎ;~O xSFŎ.sNA'*TCOz(I|@)RI\gr(ؑ၇VtQJ  &C8`u\}=zǴW#D:/Ԃ\:B)7mo_x2X[2Dُțh#Xjsi2IӾb'&<g17 &Sm" d)WMcl+٢jԀ%4uќXQD-G< aӼS6$P9+=CοvbdKl ^~drgC4Gdx*5H.`YB՜KdN.XG׸ai'dYD͘lyrPOԎzU>L JBL"bُ#GO`ڗPKS!,-Y^fQrתR~+;TbyA#e:ل,GUj2aUN0{@!3hҲa#' 6~"Z°>txi:\stC.!/tmQ+E,ٴnSZ3+b>mbB [G"w+o~  踮 <.3*짷e;˸ֿslY*TVVjUĪ֓Lrw݊x;t{ۅίZGg(EuBbνniHU]z 6kc&xm.9 Bz:͞ff>'g ebp+oWޣJ^|T dVxY1?K'Y ЈS%h9nL*Ck5~*5|#p`} 3NI@V}&$Z>oi_7XI`*ܨm'<g 4df`WQ=臋+sNqB1Ӵ+_ .Di-TZLܛIֱf9wAc8<\Cf K fIw![Az|nhGs9sZƕg^ym4S\%ԭPNuȚ%$scg`3CVU1X3O:^i''n^:c@(8yW(3\RszP(i%Ι=&Ȅ F.^{ug_}+L~̟C߂_TZ^(b!'|8KʲҊ\~A1 ؗ@JkpablO1ru4 `v#a3?LUI5Y߹dIw",okg@EICXXvns<^*)F&{ WC{t~g`Wj3l(޻pӋ*m^I+zUurs˽i NH:l+>HQOf8lWԉ^6w9@C]C +iTsO9f҈ѓA  eZԤNyL}7#B :+Y\`yqJ!'_8E{뺫 Qke7ˡ GθԠ3;ȩw4ه%jIpMn&R=,)Ur{Oʭ)qK5Mu?լE>`i%MÇ[ij#RﮑP_wu+*It_YbM&$w%wo}!B[jqcd- j o{b(Ja̐v\G"TέUK)˂6?xn ЫK*e3CaTsH"Gtbz0FXF[J܈}GfEXT⺨:ڽwUcEA[Ho^XW]qd6=֠l!'%g?pkz\gkЃfݣO9kսeəӿX4'ZKïCAYR;$)#g[+5*=.2$4am4[XHZ h +IuTjr]=p>Ϯ{v% Ą2 ~L:4832>*(WEͰ [Itpqqtp䣸DzIe Օ)tT^ˬlEJp@!C+eepòJKހZlT\y t;)nf'%zudWzP_hu%˄Ma4P(m?>mIQ][-y艡^8-$2^fu+6C;:"Bz\xms$F:T[%>3?^P>톎Chj@@+NnrrgTPOāUzͯ j(7M !FOI9s"ש@D?R+%0g|+tU \X۪0*[PdztC׿|ƦBe 56! 09:/1@\sSC5FnODnSY!n\nE}$/ 3jQ{~}ih sa@3=nga41qL3O=?:Rp**tJi{ p Dx!䟩E&F\5RJ,(3G)ڊPLV\BF.ziyhlOB#X]02:J> ia'hL &\#b߿砄Щܜl]% hEOՃ ~os; g$,%HV*9@Я?p7GB xTǟ͵sr&T+[~fѝڥ :9Ѓ\zhjOjyuبI@*0EbT &|QÖx{3OCRI[}B5#XnIh'*^ RSԞgO-RIrBKGϑ֖w<3Daj.s#{t3Jߟ~Ja]x"2d6w<:'r]j׵G&#(6.\BxSYЃ`g85?P]=Rمt5|Ϊ'thy}<ol"f)v܂)}5V>3=D J&aa;S EȘ )-cdW ЉMs/yןmb;a7RCvFf RhB5.!yd'!;jDJJEɜ*9xwՍG+C~Q#;E*N Uugߖ'C b;Jen֍uiǜTLMZuwC H&Nm~Zˈw\Kl|_/?Ⅷ[{t^.1k867g? =?M|_Ly2C&G,)i&aۋ102*Y|%{Cr1l89(+DI *a,䳹dk9*F-z5.x8+7IZ"ur#JyV/~mwMPR G;:jZӯ"4fÊĜ1q_B_I!A24 +z\x?xͻԞ{K7u寿Y w(W QiYQ'ޢk;ᤳ Sk֬w[|)ڴ늕H^B@II҃rV"H@W y;tPK_rzz:24/X FaҲUq%CSߙHv;5v~ՔNƇD}8c֭OʒA[[ ^*vG)~sXv3t;,i./:}` 0rdjϏa!Mƀzs`DgһuJCjC؄^Smj[YGM*yryY)D$cW|Po&>Ͽ224nV*EZ})|cB+k^W]vKjq܇TD+4ytsMwawz6:?l|Ԋ:Cl}>ZѬ2EccܪE`S}捔5ȤrC3n[{ Rȼ (.P.O*TPr$ׅ9@̨mL:~g,-W=&K*$yȁs2{ﳷ=X*ǯbE'9@ (]#c &@53zzG@3~g%@ —1״^ZgcN] 9:Gjgբe"x vq$A]DW0WwiUofwTv9EO:>*UjZOUqPlJ]X3{ @yiUܓ^x&U#ӹߊo p" >k{jт%À]>Æ8J?D! ˠ#d; r7 tUk='Έ"xtEu,8RX-qʂ/,~f`&K0Gl~d{-1aJ\}q=1xpRe̕"{ڼPs0ңKdwn}#q@9ML`Yu +u#$ ߣء}T^[aQKϜ\0r=3z BǻSz>D&-ؾع˶0]S} W;_}ki_MtιgUP:H"=< ߶I5i Bdx2uMB.^n_^$q#w!S&Am_< zoG)\9SZ7 ˳ֶmd{d\!?B_|Ms7OdekZB\SE.wۚ[ (N>~ b)1?|w*+㍁?дFZY7Q^Ylۮni!+yDy~|͕>~Z,Bj8(]oZһ)GgZ< 3%wS~Ĥi$TЄDt](2Δ+maS'%( ==𝢪mϊN8'5|h0TBaY5=~Dn4lL.+OY[$M:q "F^`];Y 9!sߟ2K&%3w -u O]Q5ƶK|m;Ntc{[ҿM%ş2w1\lo]S&$Hk` &9Ľ`yW @_J~Tf/[6P;7xYޯJ3rLGNyznW/nyFze~l9<+ pu}`D&IsnXO{Ⱦ~R jwV :7Q19Yr7=ҢP? P6 )1wKA~x̰ՒOۡrK)~.ݶ*Got҄ .pkJ㝷ûYKUX7V X:}w7Nk$3v6^ 븯^{/-)5d~8NĪ^@1!60lCWӢ~؏؉h,oB=Ґ$5@_3W=J,dlX^g"y io ޟ9#ЈPA22:XIڍ5{6vm)~R_9V!'3gِvC("EN?嘠Eh¸=ܛJmk7 _olŎs; -G>#88P\'N$2vkX DQr s.y-,= X&\S?(y/҇Vi^&g5aM @IZmBLr汔O :Gwh1ne!DF N%6+wPKy3R :]BVnƍK\{Hԉ$%N?SmퟣޝlOiQ{Cqv5¡:2 Gvw`8t4 5(I74DkH4iڗ֧&ˤ8)J`q!Ij7Bew!z꬙g ޖ1Z}GQ"$hJ`10U=!dt;Xu4HDGDݗ 8?֨xIq.UŽ/atWDV ҿ6_bw^?@ʗCdr]Gˍ0b!Xm>)%0mA+`ڗ تFF.ۉ!"k@q0Y wsd+~L7 4"0#  hd0" '"1!R!1~:2bmRV|h!ڣ 82EۙsC~H:|lY~o >CWE6qxpwnmm 'ݰ__ q& ^]l5 3"jKkM;pq=߱;aD=k~/0ٜ6q \o' "kr"Un}z̷R,R2٨SԽ E,tӦ߳d٧f.$ f4[ Ysh6qy]9 Eh|ح1Zd{K EҖ!GٮTh~C + /;HU4lrrMh&BzA56{8DEQ\MQO3MHg/1Sn3[ޫSC2YcEvIPcCpsRgl;ۜF]n/h!PN= fA|M'oc ;{-"+}4l*Y)~kAGf(=hs'>gy䡧Ț(e-D 9}Z\}aӗYfWO$NDK;ȯ!}H2 _8 Iz E%@!C^!?I^;?0ÙMܓ&JރpKն FJ.k,QF?<7݆J{'Z*WtyO77 K0䈱}B+`yo)+R#Y ,y;ZBٖ_^d((EfAHeIv2Q+,%~0 j79_8!|sjl."GΌXǨi][|t6ܕL01%>NG*A/u(9i5+LyB6'j㤈lK$` mq'`%䇒# X c01f`2&&{QCF]҂iΕj{ puCÈjX\I:_ o׬3OI $ k 0^qS-Ԁ^L-J'{46xRА-Ix77/$Qa$6d`Gɡč‰>UD7&7E~hD:0иB@_["da)ȍrʘ$R(yv- FGt{p^Q'JBWt)EE΍柰U ^%:=Æs绪V71qOٶBbVXy5]BAk#;Ϲ F-2[)CJ-Bc z)j{)!L6e*<ƭafchrD"?4RjarᑌĐFF=$Io7ULd؎8&6efnI)Komҕ Rь┑;_#835A6Ćf ěOPvvX=qho[TlZىc]P:J(;8S&,nMYL+J*\oIMC-e;;lK n-6;JQ=Efk'W5&0=1TԴX+*)tݰT}nj?1Bgnz~. ڢ'V <ѹѐ{" N T&٩+0l)Cin(7팬dNFbn4iY(HʟkjU-y~ҟ4MB&qʦb/<% ζf~1]TH$/^|f͒եj;;8$54XU+\LqgH[> gJ\AWK6)L[dSU 7V+<ŊRS/h&ZF-cE,Ų1 w">Qܹ6vE}烙)žF1,a:YՅ+Kw87y%oZ9xϥ84p ,ca7"VDVR ]08ѯ z=rBsHgTK_,ۊms<̉Z9e%^ҹhǥXc2l<]p/iʕ|]Ua>[-<66QE1^`!Eq}QjFPHkP_ܫH8 O=ul?W!Y9O$  ֗|0 # eQmK1zNOܑP2q,3xzCh!5ƶbj"77]P3HgRP4D &֋E(CbI }g<ڠ"U6-n2; I#Y0HM$ N0;#-A"MJwԔz:F"Oj XtރƸ˱xS<ˣIgʽ$8nǑlTjcS>Oc䖷Ptkw{J4#!8poz'eY-cr ]1^:)K._wWSO1xPۮVU{ x[!+4P!\&5rig}GJ+v}6O)\QV_~inJYUx4]ν(W~yw(;> \Lp_3@U7]|Ӕ;T!VLB =TuVJ dbRն>1"/<ӂ}F>̨1gi+n;u\`Kh#k9g j}O?&+i7nJlh)>NAmT5Dp9w%ݮ_қTNw{Nȋ[?:T _UUZ_VH$ \LF4X&Y*GЋfksE9kF L;#Kroj5+]R3r&v=|3 шZP%ɚR q!Y҇SUNFbJm=Tх. vV'c*l@ "f,tw9M77~\c NqO0+B/xFbO &UTP~7@#L!Pn#sN"a 82U+YaDVV*wACD5QޢqٛX3TFH0O69nwjD]P wrzBc$uqpbyu4@YQQ^4ԐŁ_z5  NNOp~Da_xO~"A!^\p*BdRa(0Zq걤a9'f<MGbuR|΋[a֏n2^q_|ԢH7=dM^91`{d`PQ ^'ljYK#J+JGg?[Ȃ̒ވ< mA60;5(oyF4$У -9X&N=$>xh]\SaByrrޙ'&9>kVc2 ;eU@׋4Gk% S/D+1$k&7?Ygl}_\}Eqofq-S 3RkMS.;ųika IP k.ɗ'-Dq%\`jytxud㫊a03 FFW总*IQuBboϋ K1vUP@8_ٳ*STOAE 5BVH{1K>6}i~QD4hJ;#Im-߼-guEҙ0Ǵ#}Nc$R#%r K\KGb2B7>sN-VqxZM;qyz;ĊԆڼ y_גB֫t@z-1{: HgxoX yo7N}ao^*ٹ+by{$n'%(O;7&ɟr~LbŐ#K?LR9~T3h"B!Z50Dɩ/a*u;" eL^GUj'FԱ Cs]l9 4(uq\K;62Ժu`S" M6Tć؍PոRLեh׹jf v: #kTXlSbCx-! g«MWfԥ"z`~?Yzfg[y`Qaٕ3Cf4b䶝B ERerTłu%0Pa+Cr~&ݼ5PO_P7w(:б+; .Z9$byp@uЙ`@  >* ݹ3bhEb<,؟ ta".*á@ iXS),:˶"H^do2X >$38s"`p&PB8GQ09*˅VCmA R/G1B\Liz4A?p߸1[cʗ:?3ܛXS,L.=cp{+Ǐ̋FP)KӾ-LE5]|l ˛gGQc3Q[c,`3~ZVX|^oцmf55'5EGck/īB중 3!ZNHę'>uc22kj+ pH%EEV!R'^orEQ&؇Fӏ/.Swr%tFG[@\fw[A!c<{RW>WEVL : ”D< /@.I'*, ~g[(PA|ah,#{S!x^>PoLO|QoLM'nS>@/Y+ !v²#`H\wK˜bX $BMKJ8LleIp ڴ"ZHwL6}d4 YC,EVάj=:xE&͆C$cׯFe q]h͔h/[쓘NAEzb3F ^OazԬHI&y{Gň^bECN/ d0\>??gcdNeZ=Q wlsq3bIYcC*Ẃ,XUgZ҂#W?=ިģ > T_ejԒݚm+D['(3՝/yC'hɋP=;5<$jޮ $GwVqwZW[Lkm8T"a0My3DAi˻e[7=[wT64^Ϙ+L,2O(}' S6A:vUyQx@ ?ˠS?`,38E]du}|`kɍ;D/w}SZEsT셮,,ѶONk(🏞S@!]}|hk66s6wRram} %[6^R=XТU-==#QT`ݖ=ёom:ئQ(ӶtE/8baS9+u8{b1^r G璶GV0N'7.;{$ne /JjTa@аC˚ /_j^dp|E{{8U 9*H:#qd ,ǟ%C܄q(PBF &D DHˬ˝#aՕlӠՂ4wۂ`;< ldz e< _`f=I|&MP`.΂6RzeCl h; Ӄ^l/H7 骖(К?(г-'Rh6Aôx(2S}oGj gy<ܸ?.tG1UѦ2TrPEZ:-@xZjIȻ3,1:@2JZ*k%Q+UZFƑ|5Mc{Pl=oJUU_A}7_yJ6?C4i<<~a'WןQϕf>mR`l_xH 9= XYtW6Lt}ko+ wbM  > ԣ mK}CֻurLbLo/;Zbkd ζn//94˞iu<1fXCz4#BWAe)!ʥt"Z^RҨ"42fg#݆\T~ gvݘGSF[,Ы~uj`k(wPfYDEsD-vL }XRa֜ޤiBiE&* w08k˜Wڋ7clajwt*ͤDT ȇ9ĨVϹ;^-SBXav9޲?M3qS&} FmY-_,M(irolѠW^8O*];U*bFLr5=oQZ7}.كR&q5h$nfӏ E3pƫ0cæ{C&P뙔awb?V%O6p8ѡ1Rdg5$̗LJgh"_ OCWP]r5HUmA5{\QWcN3NGAd3R +g M26FzZ[$]D]!?2,MͳܰSP7BA J*ꔄҺQe YCd_`'ܳG%N WᆑITMۺaЇ6ylbaܴQs-~ը"jНݕ.e?f#[jv _PПpM^a{B'O3pw6ɻf>6- %fi daa(% U#"o=f:yҢ_|F"0ͻ3|R^+VePcd62<&꿆uƑm &o|g~c.;Kb\b)WF uEl 6IUFn2=UtGͲ\)JNz8xw[oⅧ,+c΋OX>7\_21fxP^z9']{Cvq!jP~,6ŸFtbq0Op0@Kq9 ,XF{d M(A7R 3v*Tk:|bAF,ޡCWB%׵tDpc4[g/U"tvT]k XZ OWC/zf:rs‰laXWoJݢ,2- 4qHC  ÷u^b;*{W8 (_oVo 3Z>o֭ ]G=ZS3|%3CaI?Vl@=3Iš0!i$L"ixfrw}E j%Oba\)7dA' ×Dqc6+do>ȑ!En"!(<э´^}>_Q `FGD `Hňm/>_yr? ,'q>T"ՊJȄ)/ Oퟔ|#.C}Jȯwg1& h1kPF$m*KpEDfI,K ҈oٕ9Pn/BUPaCJ VoT[Wuto|29a>tjhAɗ[ v IJIsh"˙3)n]ǐ LaI`yEi'ϞgaCH+WK#XJ)V|=o1`lb~ =/RAmX/L'`9,ھLV#^stBԋT 6&ZSg 50'k(?@ k(l'e! Û+_n, v79G^tc(5 =4ΨaBmXGbT|y^DM>bEo󑷎bY(slmwǟ~CBk rl|%(6ɳS!zg Mvf=niǔUL*!/$!zvl/.1}<Fj ~YrQLZ(JuBеKlAeJ#GO6JE7Bz;@ ;yh#GQi5Y(\QƎ*ļWQp_%9M*qX 1DǞlߢ&4a@RT)ׄ%%f[ /Fp,.MÆB|^~em76֋9/Rtn{*fH006RU lxqּ^NɾA =۲٘M6YѴ'(& [-M`Kv'{:>G'V,[dȼVԖ̢@:/ti\;a(A^5FAH*'ڄKе05]:'wX- ^ߊBj CRJc-{T17:'#4G j pLB>)38N9rdՒ9D8O,q"% t15$AB4]8eEt 8XlEm|dY.Igt+TJv m. f4th2_W/i1=u@,$ 3R?D%PtQHa,UXwVKU_ZdtDWAǁ}۫!Yxclا W?gC5!d [vh ( -H;* ^=8*;;/v8hPl"lho* 7Q6jR JB[ߔsKωR'sݚ'7jDG:y) ݸҲ;%Ȧ`Q ~N>tu[v5g%(T9"?qڧ^&<`J{m"ӽRdMOedDTƤ@f5 d#de`jr,1D K%5Z !olԙU(,t-N.`: 7qxjv!zwa΂R8Ԡ"\N |ϨWq?C4"r$ݠ388J3i%3ek鳹<v%%S phGYn-Zj?xr8kOG@SNoН.S<qيU› {ki_IچG,2 I )xÐT$7Τh{PBi(Z< fM!#&*/Qԡ\0#dͶ alHq3y}T/Z( ORznBn>FAS}|2*h_y)9gqs>X}x$+tIܡdf./sdeZ~WKH#qT y{1V6rW!GdJƠtM! lCQJ9uc>S {ͪ)jebYz?RE*̀NkR]Q8m6L X@* ɀv%Jb}Hl>ZG1JBk*S͜眤A`40E` )'j&z)&|8\*iEWcwUhTl5 n6r9EGɖ.tws3ǚzMDjp1:f:s\5q>=LggBvb[C6Ecx?$>'֦O0֦%27G%w8l4ӭMJ]I#{΃􆷹Y~UNdz!Y![Nb#x-re>P]a.["IUz6[NŸyڕ3CafGgEI8 R"P8KL#k" =G&Fwsd,J5@ܪ(!I T7_iO`kK-eAdw=>-URG( (A‰^(w^$DfwwZV٥bbFesThU%ѹ(o zCx#e'@ >\*>-ϙ Q]c>UF1/^{]ih~CB|:;ݠDkm8H7-}:R?FL'_v}kY1 1L3kO/АP`a7 |fO:&%;CaƮ&]RIְ #hєAU'&U^-Ʌ P^'YٳK퇏`!I̊'Sz2a1$cMTZ Pzx782xwJ<PnP?X&%Sx$,A8DeN` 'x{9̠ hcsBs9TAE8 LFYD&7>{ Kly9_H`ƀ# JʳhԻSY\iD̥g]Sg_/P'FlЄWIuMhJ;$"DK+z< lolIxivl7.<,Xs@e"53N),4'&.yQRlҕT Hϝ#J"JAQ EеȕQ3%!p{=82$'t, 3iLWg*FZbYQ ,p6W[J\0$d8lO9&=Io6q ~4) [*nT- <&m*[-Dûwg M20TWixRê\}!f*=h%:X&G~8KU<$>@_m֓0ܿ_@-!i_0s؀T)Yy'B`^S8}g)KeC#"VCbɍ G4|u{#Ua)58{4J0$qC1I_d&-T׸lBLf,=q%$jU8oyrZC]=/<7(߱$6a=||0ꓻJ`i֍C 9vU7k%eU8vhw_{_~0-i%Nz";c]+Hah@% ܐ]{Tp'ڛ E)}SJxKV<^}& "Xw-%kSh 3-[c8t_yb'>F"9gpo=eHr L2׵45+] ŒWm4e+Վ\ Iuz LOFM?j؏$a .)&Sqe"d S>kf"OR9i#R|ݲCo@ō0O ⭉ى4Z"9Ie>i.#gȽpx/:Q/XN!r"GHd`;75Aթ![Tao'D-|I֟!9P0TZuj O {UJe.;K\#K,G..qRַM<UylKi}cca'w:h"ܚJ zЩj(-ؙ[v7 4f.`H6L $U^vz S;<5al_ 9bѱtQD?~nCh+^]H>dzk')T3Jg+['K7,~ QRV1Lc ;|:nP-KWuq 5c8q*z0bjzV)'"8XB]䍸5E&Sj`@-QP ґ2."bbNe/[*&Sv DaGg_,FE/s" Ĥ* V+Qptޫh׿NM ۺ z)|t:Ҵ=i$¢{ڕxC-kK!>a'_G%&/1iD޸LN'9RY,V$2Y܂Qex6[!O5<|07x8 Tݝ7؝G;M@0pb-12ZFy*DlL.בN۸s+O@4ا?12̆i , G?]K%81U',%z(JoQ;B@*mZGρ*&g=l{4}\ ͞F2I`hgF#7уpd{AkoM67QD2.{HL;$!Xn$Vvz]վ[2#IXb2#OZK !}˚@/0;= c9WFGE)ax%i(f7 ǿ0g$QZ} :?,t<;CqfRrB6; dN'_]?o唡k^SϾ(z% BmRet%7^w"W)+' 뵊lY")Ec>}~˥FaLtC~nb|ш$=_U:hr{G_xoטs0 m},'`N_V"][{=+gxߨe U+^ )9r`=+K%\D 7KYvoQep CA]x(t$Αo+PAd(d[!Nԁ[ s§4- }y5lWqSE+?1 LAm$~̟e *%NR3pd8D#VOQQhCb۝}!Y ]_fB@w4?+m(XL;Uk9: Fa޿(#2mO8:$>}X UЃO$ T'k!gZD/w̭C <^J>UKp0zgG33E]-/Z)JE'G7huvޫ=S B>2 /@!{ qQ:vJٌ#GH0B-'Cj3G55~&ԏ/^c5UyڼUp 칸i%#|fZrIU(R ܲE2mLb㇅+r︥<ӊd[(0 zs4FRqK|wXnr*st΃)QJ2f鳃c)Z;E0 q<N5-t\A$eslϭ0i98X0="\I?8MHhe=ӊp99击,*xdҢ̸Q{Gc0#f[ S-Ҭ[\gl?R<<(ٳP`i yϼ[_"

LHSWҳE>أ dfb[Ի.>!zE2'YX kFNH'w~dŀBx _J&f4a5% XҬ+ #y ym\O_D >b;)/:dQ\WWCX hp$-̥gxwxwH[(o|?EAsgZ-{h׳gP/{8*O5` ,< o>Քv[J}Pn{+By)[T6b?rdWQP4!R&u)}l6֯iDm˱ݠQw|k3C/_OB"M[ ȝfi/eX^bq|'1b?GX;z'Mp2W'(cQyDl)΁*GI88jR@+o$@X"8WrN;QX s:_'^/.Z44Ii+wr e5;[93n2Q fEfqnò3!b~1g!B4/fK2:sḅҹ~OC;FHڲ]"#+i6DQcUk@iL9(sXw9C%/[*^i7X6I9t#xfwTLެf.ځb׻.R;@ݷ rUIlOk={[r)(25kӨJk7 %@g9gb5E _TLВ \RF6r5BGc&;)]V8z*W%7@<~mn&y\߂a mzBڲԂڈjd]ÆF5:`v &Ps;IhR$@!< K^_s΂6-;-l?tntYE-Th.+5glA^CU vo>~-Z%-))Bg]@ 0cHU^p@/;NރeD'n/ >l0n1j"aG%9gιU^J+ Y4RL*v"ӫt݁GH$nbxʍ7\~w4FŘRY)|sXc!H N:Hiđ}UK4PW%  5no]O;.w Ԋ6 3dun(X4-W?WMl`g4;`Ԡ\Qy6p#.c$^e )D[Tb@"yTYR Qi ׾pᑪDґ~Cô CCq/}}h@ .]g[2۹U@D %U9҇0{l\t鿊IED`A&.Y&{?J7Pj]`i ` H-URL5`sAɵ^|^eB¿Se 8ib] M`MU>EsYmp*z/KSHL*k["aKQw(|$n4̳CS,M3޲׎v/Mg M2pa, n.{%lPPѦg&]3ٱE$7o&(LR 9]h߽agi}U$δwԍdw{$ >E[3 n)Wt55ϬBb|Ban6Yf&neEttZi%/D7)Y;Q6S4$ Jǟ=`Ly]~ĜDāpm<(>֌Vc4lb+Dgᗃ\$O|7(6Y Owul#}Qߔӷ[6=|2Z0>awʢK+"xeS){|lKkE\9( &fID^J ujɢfo~ܪOK6@*5|TΑ-6 0Ot9Vp7Ŏ Y)Ob ļf.|!c ,~}v=H- StHa;̶dX?2i/iQGdar^BQp5TL>J&&8IGυv䷪.HgKR1^Bv Xa=ӻ}סv f)qqy(ȓ/"?x@*zZ}~aц.O#:v'MNs-Et~4sюonWbUEFA/gbȄ= ΑTʁquuАi :~țtwVö+?̹Uֈ=2[06<ܢAD ?!oz϶/*)Ahn#i V|nLroB{{"v#e)E3ki(qaݙT\\Ng}0s5otMY$.CxА(`\Cj> zl(IaЯySԩNm[Nd%'!kݧ&aS6Jjt赒XuA 2-"j%ӖgiCU޽n5rЎTl[[mbT71 3/CK+ꦤ#W p#Y0gBRYsx7]ECB vk"0E,N@m3вYTCJ委.|w)"h(ĝv+DNU:Or>v'Gh ֓DF)Y |j3ycwD+zP%/ : ~Ipߵ Id"C۳1Um@)p-R99b[Yaq 7vpB+CJT4Ko=$pz"?O9 b>!yK4cl7 )jxoxibd<˘AZtIEL*eK֒Ie2bjyX ^u|pu+jY_XA^4ء'OL~$YHB2.G܇`vM3ZޱpB8*cE{AJYZ (AuMG*]ȸOw(B#z@Fl{~K7RP4_@M0s7$rN'n $t3}{P +D~v˛@ 2Rh4D};p'(mYL{o/ tgʒo@, Q i3~I]'S|d,\* Bt\ЊY4`{Ņq0f±{ש8"5XJ/c'YqS`oT#&KHD3W ; zyQv)2!g|1h)˫s %a OK!wVҋ$`ŜC_zHK'e4yn*T8vW2\M0LQ䐒,2NUeibEdŘ4êg_pd;W{$DF!2B3SDr- kDjYMuΘ"T˔v;w'1\(e,0jf Mvn޶A5BWS\jJoB,%7!ﺲ+Qr<z} O[R6&t+'{vn5Җ51W|mj}S6 %dXdK^1}E!*4APksiw( Yg~G6sXamT @8!]mսQPViÕv/*P{@ Ll@Rš]fômM2w׽O>/3ॷ*Ѿܫ_8^͌ka~2خT(OL Q~zIa݆6'8BlM. >T#!8x^"z[P(5F~P ϔE"6=[BFI̚ N9.eT3¹8?rOilKrj}_ ^oTˣ徥ZI. KLK\8}SFi P='xh q` 4w UA=1hXdB"04$wx$8\tg#JN&ETR{a*#Vp6?knֹ4J@VAۖA M+C.iR!f^ !*/h<抉nA>p,X r(u5"TPp #XT/<jR{z?Ш5n+X%Uw_:B"Hޏ5 %F-b~@YnAjKb9jcj<3E 'j6MP z}zDŶ?8=uX6,iO6g["ũD͘82USln]y5 MbE-DԋU`|@"c( 2))T/quԆ%AltIYV, .T 1!ɂ'LE9c@.RzRQ3±:c|= tad؍R\~Y7x \BԸ=fG1xr95[3D:032yLl$GڐV(.B6Eeݺ Ee鏌XTP]G̑#wpt,$e˖{;<+Єt!X h>]2y;d Eν*o.:aGz5}l/{C#fCV9ىIIJɮJXk@~V3tpe:^P@K(hDIe.?Nd^DV¾з ?'z L6gj]/&[3'u)N0N-͞u{_})dSVSϽ)LUDUUka7nJbɄQ-; Tv)-=|a`h y Tf 谯]-rSfq?}{wGitYQ&=;tX=~3F#(ޝfB _NJxzutn*΢GڨEn?-R8u^<}z^Ig*ojaPȈQ^{ x7>wxbpS篠)up x ę< ;krCO U #uaG Xkf]Sxۮab%AS??l A$81 <% ϗ K5wU7M Bi?qֻ=츁cO8;`!O5w.~a(iàc<һ"{lVC=Rdfʗdʅ(h«V?7Ѹk,^ys&TVu؉@R\8rǍe`P(Ik} 6{"(d(d6\P[4D̨g;7B(D`7^T8ff:lkb(-3oRCNJ̞=kT$`e 1LX$5h9D"e?S9ulA\PpP&%aO(y D(;J-j-hS;3u;jxd6WkTXBn*W=YuK}?YMtǒҐk/Z)uQ^Y:;H: m03,2AKTWyH䑁H3 @xyRޔ^hhJ% o\%Mq1GXmQG7ngJ=:,w4m{ wk 0J&&1uOTD ¨揠A/Дb)RB'5YDC:@4 HC1vO:m*>|krK ~FV8ې՛ |>4_bep-a tշR»j zR %R_A?X`S.S?:w1Pv()%|ߥiR-PFO[ih[8~s ^!  ̀KsJ [$1a: ۅtV8x TXcDj>b{IJ6{֚H+}ݚe|6g2E5^P߆@߰QOJׄ~U"z7l{ؼ}_0*ƍ-i$lKرTS""9*kb6ٰN'ሇ_w$?mDŽEխ^TG8+ِ*SzLYuerW:!DDc:ĪJφO<;W("@EYbB;:@Ju7`:={٭f rpXX<PrE) *|u4?.$Vc_a&}> bi1G4ƣfm\DH5:ܡC)Kf!#WиXK~FDzϚ{cYPaèb3E ϩP\&m:gMEkzb(7ט 88 ϐt%Mq sQA$V-B"1x],vrW^BU]Ui"tO|\hp)@4P(_}Ǎ;6.iOGPi1ByXj1%dڅ2"pވ9Ub)}Tpn,a %=˖(g%h'@pD!"ﲭ'M59"\fa(N[d>)]FU]t.nZ%<3/ny$MOgm_#+]5]*_.1ǟ=c=:HH5NU5V4"2dC1 5LlzrA yV9=c~!bl;Z8oOF֫n-'CaKNZD~5t ]J>ȳf#ى@?_yK,a<+%:8*to_7QjbZ=<{M?|>-. (a);GoVa*}"jYfgɨxءI&a:RH%6P C?b=CVZ._h5C+A3F(/C9QE=RBdBdּ>cfu+YKdf͡dZIqnZR OmU Q8jtUa7=łtr%N5 ١ޏFI>$&cNSӸz&NS6P))U}Q{{uthpP9 f$\ht P!ڤ`E\K"\dpP§!4r COduK v"2d>aU\Mu !!%b'L%5(ӳx|pQTg`3x C]R!,tWrq_ĕַS̶*5^ҫhu,mՁ0J[,j,WLMP)(P~.ꆅ }}D!Ȅ>3\ i~wpٰ1dMȤ?{ d-& zX@ 2(x0s{'̷nng,-_e_:eѕ~8 `{woS>={?{~+q%#ͧY Acz:8ʯ֣捷f͜/G=+<5:UWX _8Otsy?x%i"Hte) : ZnS*&#E(j ~9-&5:f\IwD:(;A9`rm;]3ly/@Iy CԜwhtF.FE P)ِ穤̝z1*E1={jVNCe^@`b4 N/Rri}#"OES@Z]-=ɴHjQzo/*&˵Tsh7N\s$fO>F7kh-عUM5*^84?orucJkJ *BԲF+K݈qslɴ'xE }u.﬘h8͛kb7а:cK>&jB5dB@#).Ʃ.\*A7 z|PfŦN msӹ"Y ߪpٕJӡtU(rrǩ'dkb'NIEJiRaQ`DT yi AK;y]L ݮgQ)=@{(ks+?uԧr5effB.,nkȄ":.OL[ FxщNYb|Ճ ]y(x:ܐK0VDLP+Mo`Фa2:LFcp|շsC^1.ˊu?ηlYZ\G15[)rPޜuyـS+o^%: d?;tk}9AMDp`t0$`kPV ZmMuM*F7( -'H$Rm_IJgyFj^g=;\k|AWR/-9:[T=[<15 B:]:6oPQBp漕yȏos?%//:G2+L5:nȉ4ܜ^ H%r&C(y5gAca_EyHi1 XBl-HHbSk *J&XԾY>|wE/ңIZr ȵ?((7\]RqU'6x +|iO? 뇕,W)ʭ ЖN~2vxGDO5IOAy:?O}]-宯& կvǞ»Dy?'nL{aOQHP#9(?wĚ&0 ~'[PsS$ A{8[t|fsf&Zxv,TNٰpБK/puQ'֮z*\"y r//>4XF3 kJZbn؋rlۻa.ͪyuFo3aȨ' ]U{WyyDvFٖ{ S@%ҏHG#gz64}oJ28bXr=2o^z*/@tO'vOq&=nϿFvzF(i4A|E4`J{-?pfᄠELmu;r?Qw[ `[ Og;Sm={/$Dpi9So\ZG+iuĻÊyZ,f Q¡N @ك;_gD&1P9G/ ٿMaȆz̯"ȥ3[Wke%i m&'V ű/0"sn<N9AnEvjg.qD t~y;]~=SN.4%;a-vC<9Mr"nX 6?;< oHl<9l&ptxi{J"75pb27ď?ܿ{UZ59V{Sf}mTNݱtH:#k﷔oNɎŃ&Xf6}IrKWnlsdL%eX1W4 F?~M{f. QwhKT۔pQk| ׋cd)q_{5߹T/k|f:?73#Pf+8zl.=]Z*uzERsX3h4U؂}O֖eJĖw+ j >[c%VQlnie‹z:1ަvm>p̀|(*X*.Փ^#fzɪ鯪71dc(j`P bP}>ZÚh;~7˘o{c9,50[st_/QlPR #![zݏ=3azYd;]R[XP3奊vPEkJ}lGOCOdXwԁH9I־Y-~7uݩaͻP1Yk OC1~x4.U ;Pg; 7wc0N廵~ ʟr9 ?-E^Bޘ i E\XTו kW\ᔨϘaZp˵rgqQ2 1$hÂnF+D`x o볯򒹗_;6')͉piJenfu:tDֆm𾸒kG{P)1. sm/7(WЏ,3y%c=TePhiӞ\W\EJ"*!4͝ 1`<[3Ծǀxѳ>|yݢ}^!Noytu1q[?7%brD9 [?qzL/]sùP,Xwd4s"L!{}'Cl1命lʔQs*^(>|m=Qb~S?oh1G/5~Q>z(xx@wQ`=DlC&H*Y0gj;Gͻ ^F7wi&x{Rf ? T*/f[ڝ~PZ0Hzx#?M"sp3v OdA|K9rG\_AE ǩZvf7/p#ʤx%"[jrd 6# (j|G' [x1SΐSN=E.Fe0g *$E'Kv2x&.8z]䔤 MIULbϡG#cz5aet(,P*5gkoLo55}6$ӣ;C=Yys,Dc-Q=LOsߚ32Ҹ2@o&S_=Z~~q!MNm{z* m 8B1|E`2j U =|c)P#@#'C>w?DOcM 4o8!g3;S#EU-^kQ1j;h(6s+ <#l{T^rasL1,B}Z>;Ӏp]4DUU "[mWPdMNuTv0ؘy5_QtQ3|7~O(܁rwL A8n^rL:/JL{T:+-]DB#_lLIYjZpw"_0l}`FjւHQ{u%,9bt]{> ğRZd-, {`54| SHa=F|ŷ6Ƒ2Sա^2.A64zlÏoz󛜔qt8; ؤcU ý,fl_2na&)=`(*kP__u<ۖ4 zr^0EY1c_o-8Y~yM Nzo Am)=gj[er@T!t-V܄K=(kq\̄uoHreBno2Μݧ5-9&ո=/V;,=9!/>Uȉfwh;w\*7dݿ7)~0&vo)>8ǐ+z+rjyHAþS8bނbcjH6IՎulW j C ~](!"۫D:REs>'3BQ&%k );#5*ò $Y֦|1βoPI\@!xxg)5]zHS^U "9Ͱ+@- bMxv֙L ᠤh9pie-+'! )\▼%m_"^jɰ)=LJ3$˜/~~&.=Q6A])>#FN#7$7sZI SOkȟ s@K/rD@[݈q0"`89V\eJS%&s P Y| ytg$}VRIE$޶ ?e ]s!us@n4aV]ˣኲC_6 .A9yR^'B;{j~;od$e+?‰4'ֈͺT!S gљDJʷ2y`t2: 8*xlcEaleUXW&l  ҄ot(~~B] MX``YWĵ|g2%ÄL2  䄸'$2`Ǜn@'L~ҵ*d)RTAR 㺢E?Z* & @Se_7&_8(ԯ7t*CK^ŃNDJ?r2?I)\arp^wk*m M'yLjJ‹pWw@R&2AHJ|P t裹5}wyVp"` [wGJ/t ?o5;g$ݦ\_jjw B^8༅k5ĭ z'\B(A<+|7 !K"3q DLsDJHR^X~{^vc+o+|-m@BjVyhbB짼g.m}}1y :~(wKHn=~(QHګ.GUߦ:+`dV6~<Bx1TsUKA)qH䬱4YSN,6V+Kʖ53FYxz‘O3ĭۿz/\e{jNBNGO{ZUJIFTq (P^;&ؗ\U"H7).JV-Yґ矃FEH+.QlO-2*SxکBc8Jtl^W^I,LDMd_р\$ ~{¯'UG cG+_A\(cX"dΰsW4z^1 pLR{.[0Y }Vbxͱ  9U8O5 RT[i[UA޶xgʓ7)I$~Unq(EkQ :Ф7lML;ygUZU-eCrXyP-sK"ċUj8!_ Gnr@WC1 =wlZ< cV uxתRBnvP&ᓢ# c, ')wd%VYЏ?SbSW-W؃N_a._a/5@?>^{Jn3)Vvœ|]~;5'(@ B~ ?ԁ8dxӎs>‚ޱK:WI.0S(tIB$GFaǞ/d^*jB@F>ro?]-X5(jrs:+5\|i5O5mQKױE>׭^qxJ_t 9 ($KơC0\C_/Ur(-\H4 .<B5-A7!IFOvDE{sU^SϦ(“< )xJ3G+CLdzd 8rfh<}DϬV:p@i YW)Y8_Q+ѮWD>C'#Bb߃vXQyQ]/!W&IO;=͒NGsͶ)e [rIg>S)R݉2[y̴fi[rS.+Wsү&5OJ s75vtҞ4Ù) Cuj*# 1f*3fGO?2ުqU3_m а?JU,KsMZ&|L]VwU{N2Hqea,`JcV:u21+$ի_`1 ŞUwcŒS"U)I V|p'IJ/z$ dL%#v"| Tûos?QT+k^)\q2)S-/g"3gS PWShuA)B XNO9d'o7x% `'i\9YUL?^P4-(T^jʔPS\7a.㥗dJlQr-W8;vE=&ZqU{4 $"G_gӉ5-*/dPڙ6w_\ B1%hਚSຜKWm6wԭ?pLojï̺~A^v\/P-{0DG1 Wupkb)"vaI;\N;aY)dNUퟜ7?ьL/G6{-?xVw |ݠIDATrzo; 2o:! 7}H7!+ _ߝ􉶯D:Jv}wWoKDozJG6ODvWY =#F@4ѱÄ5.ƻ$I/ q>Gg7QVϾƙjVtl/K-5rYYOO?zګcnfVzg0}@C#>SYrͤ||Ǜֽ?;áv<_b71xqoOK6?;4٠&/,;C'7zn9w&޳/=_.L.r5y°,%1)!{Om7lC?];޾`gt2S(yL*H1/̍A<_׆% Z/G'<+A$v@Ϙpev=F֬T^>m=j%G}oiS8ՖF ~Ae4'X#;cMLؙ{[ 4g}oMZ5}-渹~Oޙ[D p<]%WoSc`ir+-\$(Jcq /2f=zQ:G^, ֩vSk뱣4ZG:p{` K1ZvdӲq%:1=JU" d9O?栞R1,TP kկvNC>fK!~f(e]կyf%-%~($~(@U20Xs3bv}({J,_>.mci 1-BN=E'\A@9aFz~ۨC[cXd^zc&w;ċ2H5T/qpbUxv֐5!U,9sQ#;z^d>>3ݿ#bk4O>Xp5V5RIΖ, YHI(Z^F2*_t5rvԨ.H]A+{G!|_Ɠ }ƲL\bḣTEo%7A7ʽ%z94FMʴ1RGO%>륙N_DIvمhlo/EW'd?g}sfөX{#>N?9%&NP#zevvFʙE4-iٖ*ƾza<#)ߧffA{?Ah9!3"S ^~a!{(S3n tn\lS:0HL/SwfglKz|qa$2,EsodiB$N7}[? 7=pt3HL][TȻVW\|E$zd(Pg$ +-PxP8I?LSMnV\?4ݝ~gypt17%`}̍&W8 <؟Vae^w&2?;tJø[~7x"`ei)##H]nl%[~N YnC b-E0x4GΑve|]5%qg6WhɩxnoXw^:˛;@E- Rgq.cK)M{~e,京%#8+@ҟX<'3w&=ʽ"8kР=&")1+e ]ueDXO2*,#8wrJ ^A^` @.^99aWt3);\c 9aٲS>X3'?/\&#խR|qsTW)xPm܎c1CPQDpHyEL/i<2TZ,Ue_2z!Nip~m٦ILv-ĸ2 ^!QdlX;%>RC{CP>[Y lTUMWL,"co$N.<#']„R(= d1??7~,B} ΕHx0Ut#zǺZjQD̍E&Vgar0av[8h6 .8Y|?T D3dR$bqo&CO?)-/vN ,g#~ߊJO4/,!2眓с`<ZxJ3GN2ǀR )zw7ktgvyqVL08_MQgnӟ pؽ{=MFGN8^Swv!=y[ bP0߭u{3,T Ȝ|d{JDϿB1f#Q`)ٚpAFW[|Ͼ|`26 G|toF/z{ʱP-l:%f3uV)<9ȣ8^v0yT*0щuE 6AC1^$D9,~֐å/yk4wG]b>R Okm9yd‘w(ݱCI\O3HCHiGOwy)1Fw9Ylwqp}:ՖF0d*]O2z5J{7eroNolN"UjF/ta]_GQ%;j׆y]F~,\@fW/?SUݾfSWGUK)♰):C7*#+DzRHPUI/Z#jt^Wҫo(g )ЃČڦ0yMR1ظuۓŦ^&C:1`5`^ Y7_Kc&b`/o%.b͖3oLپ0Rfe Kdb'< ^a*C jax׀2ԳR|^]v$Q T!`۵KY 03Gtlܺw'vE~+1gģ;^4& G؉~N8"]'E' {_('>v.UC)k+F$´!HUtj`]U"R8T~w KBC t Tp);wuAST?TOIFzG Mx`[]0 6BMhqۮ/^շܲ%Pm(q m/wW gUmL4zȧdS-;(sZ>}g50!Rnrʭhd5uB'E$M8;IဨMV^orP,_f\6m[ _XT7$Bɭ N+>2gSdaSg>[9O,a2wT}kYJz-MFGN Gs)ȪtP@1#f(oRG%.iJ.$Q rJyܜ.Qdf庭iSP~.Z R"6BE0*Ĺf"h&tik ^zX;zo gqwdCqy K$ Ds) M[Te!'l evd3tU9.%0SO b_3j߃#Qјrs$jhRez(mٺD|pC$B$28P p<>sm[47DT^tY)Lu>G|%to/\QB?DN40Qpb3_NzG:nMl܄+?ڕG`f8A/:NScR6/(&#bTMuT`GS\!5n*V5JSuˉz:s XR*ĜeOIFM8MR'}׫>TO`(^Ϭ1!~xۺb\_ⷄz 3j\Yٖ _R HA26 '_7Nyt(nQ K3$m_I? 9 ,F7_K:X8%k٨u?,+)zJF k/6 JZ?j' RaM 26j<1XAuBpHtjyd9}@ma$wc>\ZS+ æN9.桫s^Iӝ/k #žqE$=j\,E>4Wv_4G5|\ ɦ](A %i240E+CE@.z? 4V HD!ݳL#ղ[t~ソɳԀ>5K&˝E/D|f.^jlqHlN^d ]-֔TCSvIo6l'X Ea36Eụ?p]vYNW+T˥կ' )(G "TTGYv3YI'=LmցC 41mDScJL69ei/HZ2'KH{iwˡ?M#Z}T]Vim"nXoiןkZmւ |Š~4:2$+KÇ>TdV&3L.Ҽ?6][nO9?ѝ#bp\?P:і}‹]*vն[N/ǍnvWR@CWM_ɡ*fJAEcc]Z[#<=%!Aݹ+gA5q09#Ro<&U>+륙\`ݘ'$;m<_ 99t'G? =PϿFcx#hs|ZUi߶sOd-^Ѱ]U~0GZv":31&WH<:1\;kH`zޯDiYB9J++G^]=*e@RڡUK,}wUOI$kt&/ZadJ@tXb+sKnAxHBITi8)y4KbA? B1rJ-&|P#ݏ`fTp $ٷ7͈>OMLoJ?ZGq`פ{}G ٫mp{w|~wȽKzm{Xߐ]&CYg<;$I2H &$'P'0R {PrUs!r1Emr?n 뤃 ?!gK0ׂ%a4M8S2o)~}/XZ8oe$yq j׮Lj/u ŝ1/tC˝]hyH\Kɼ/Q)iԪ_+.1#ǿt'Kyq5}$q;3ot(BBQF;3P~I\ًK㊋8n =ۍHmv;z]N p9d;o-6% iNз~tUȝRۨ$@eQlK$lI*'CZPzɓ2͡2ث$qyRQ亜|K, `6 ̖57,^/rss/8O19rlj*5 W弔ۼu//i˶$( VK{چV8ywIؙ0+&%6"\͡r E̫u+7Y+YB"9:SS8aJ 0|O5`~EK2=i"d#蓲Eی׶<XZCxyC\zg}Ͽs2B~4R:a^ ,[-c#:e8 Q̭7d'Sm3ds.Rmұnz?DHFշ?S̓P sVـDh挨x|]`~>DE9ڀNVŸ'E J* O?/X'4c=iB舫 3\8s 3Cݓ8yyș6F cKҢzځ0 f"<̙]ds= W!]@II9J HJ <頋 AfҀEn C2n`2)YP5^45A~ppݘ7ޞvWXft 8l#('(CcyYao vI="gȎGt~ֻ)A#⋯\ qdـ9~}=]Fq' &ndNv<2fg51`3 x#'(cs7CuQN;^lp$U'VW+%nuf,.H,:S |ïg[#3ݟnq'9z'ศ5;ʩ'LAͻH:D>vɻ ;ZggRGI>HXR#V!Z|jW B=&?i"kr"䖊6anu (=`t?{T$'*$:qI D!OĀG[A$Λ -K龻?gPVƸ"Ng4jٰK$-: !=K_].󍗛C-uB4vI٘=z<%1ܴ)o<=ٲ,<211xШ)<0O+q0|dl`yC\5.w5I`' !FW9"u,ḧ́~OGi/<h}wg.%l|ӼaE٥pJs/`ny~T' sR^Ƙ~5#tz`텤 cJ.$My8, j26{ⵧ˦jXٴpZUJoiRE98jQn`c] P-m(gB83%gto kԣ1 ?pds?LFr5AH'"-V,ĵN{z `gv" .3BC/Qeb7_xܪ^14%, <^K eƽ+9A;PאzgԎY4dI}Sw^Gt` &pZ{_jWb`˄ߴ0ux;gv^LXyc҅QXďd>J;8m"h wɟ3EQ uAu&1z<]W/0BzUK˗ qD}sn P*ЌđJq}kC!~/zӵ#aV!~$"73<Џ1}2ecb@JbJ8h̟=61(G#)5PZ4賢HSEr~47T{KT7ҖɆ͸$ʟ{ Tc٥SMh +|؂_zSaʥ zlcI"-wBRQ7p$хB+xeՆjߣ" i& 9r%O;kvY]<^!$|T,]vu͖Jۥ)yyg# #z("}P&=3e"(?( :,r?.MZIT$Lb仪='/wITh*) Ow(P ,%S#%1*W~&K+#.Bt+˻"Ȭg!B8W(O'.#n@619vMec%dHHfɯ>rSJTIiEcCx{3:9pp]JGhp)(Gӿa5Yf}8wrc=uD|IiMpEsrOaqQvB N&\WXPufQd' =](z=u8&1z[Ľ~0PvBWPEJ=qmF~L |@ C,8Mk7nǘa(UǹrdBa1gC=;Boa,Xf+bgp0*;!B/"&x{M6 ly,UX=9"bk0h$y\r)Tڅ)Cv"lEv#ņÄ7fi!`;_Mg EWL ?,v) Q1 M 5:?Df7rZ&ؽz-,oLpޢz]=›wD_HyMp-ڹט ;Ca#qv _`"~]~W: ux Z3v ~_}XΠ$>ZJF%c02hI;ffu,^2/|3x#S3iYBZt>F(zí@4W_O%F#)4~?AnT\D2hVoўCer.1GckV)AŏKL Zr"OIV]8AбeUqtޜbL渓.HN?)nVFm^R%ΊM!P'/3dO_ ҿ 0Fjz=5X?^j B-RLLPd,qDqtZCJaMTfu[)Sd)3% e؂: yұOvH^$:4"dΠ2YF6{A4NsYuwIVX(jӎ WZ&d;Aȵ|"V ybBfJdP`[Dkz ){D]VAY]isjxOL"'fb츮wɧKԉMKW j zɒ=b_EU-5,Hq_(ec+UU;>,bJnK%ʐ>s~¥)?;_{1`doLQy"P _~]t<4g$%w5Lrܴ7}c/z(-X@ciglpG2g:R[4n9JPɢT])TEi D;#--]<_eY6[b)Ѩab"=}Cd^zmG6Rk I=>!u"]^T-[+W]{"Buɢ/HJ䉑 JiKȀ> a+.8}#ی "d~Y,?xpbyxa m_@Č(WNSWjC$%F_q;nãYI=hx+W9ȯmyrKf/~5 Z gG#Ͽ!\iԅъ8 Q'\BYBNI>w}B&֖Z!L(k)\xe(U^_ %_ Q֦fR6*8@*^γҝ1eRK!e@*dsϑ վ@j}Wsr>/ Z{ VJ_`{3)j9olALi+.،>M|I/61#Dtr+?Tbp%(³s>X3`4K@_~gyCf۾h ,YWb"B{V_X|=NbH槟_i s_yP?LV;=Ne_8{Tpreby^N ءNX̣2 zV~2GrX^Lao# s_y <\B6);m(6'H"ǿqW@ih ̢I*.vrCQb_gjgH@6L~~^P/rpG35eM? )ף9ظ=c} X`hGJJ_0&F yPYHnBqJh+ׅ*y H'y#KޚOJ1lC͚%S߂߹cnv>PhZqcݴ@2.ޘNRE}ʱpW `7'x)*cřR! f*w;V'sc'o).2=b.^ORaq t+E4 rn ݿ{!:wOƀT_,W ٽIPG.Sczu+!,Eh%Ź溥%?s-p wo/R0|sRK(оYXWA߰ի67}X?(K`FQ FMN{ P:F?UŢΉ ޞrF/Pž&5zzys_ ;K_{ܹk PkӫY9A0|`%Zf n}nt7B[fM!"seiY+k~ z3T /R |&nT>K=of̐6`G`Cwޖ_ߪ3i`=[[u 5<)%΍zģDiD*]|"ƭjμ%&X ޑd) n0љ4̼;sҕa7*ꞒmXK>橙F$Aq*˳dd%q,#jPgHBHzX+w3l ]yߙC%R#uT(G\h @%,Cd-k˱>7p5Q :(ڷk7lX^d,g6+,%V *ҕcz2eTYNC ݎa 5`)?Kq a5jG+Jhn*lV5־5n [+\كMzH ,Qph'>+ LQm7p^nZnη4v8WfzS9$ρNu$ 9|2ț;WiƀPURU2T DE3~|В퀐dQP;!ʯ)ayͅCu5%C+A03_H{WȚn Tkp!AHbDƻwQs?^{| z$ظXC63s|a믂& REu'̽Aɀ2O+ S{d\foJ뗬ĄF0+I~N2J蘕O]iM-ܑ'ǹ8ry=͈i|}hR|eB8Hr3I`"O.;CeSx4 NRY뉞\<K(P3 $?X%E:T5tvǖjq~hq}^|uS1o+xZu}#G֋4 Is(v_+##D{+?M9BMLh 5e$so.'0*Bvsl ,X .__l\Px:X_&>=ԢAyDt۰bJ=SN7cw/-Fy ]MAvuSExR{CD9bj<"2j6=^| uF`a96kւՃ̬WTŻoAv\A3篸"l`8YFt3CPB1_*v)`€T~v,W y_(^; 9W_ w䫲gəNG,Z7(◯􋯾-~ꬨ.d+{BpQ2nBx?1(E|@6&6sWD3E㏿FC:<X\Qb@T8%N=L:P ȩlJхVllߥd8ɝY4K ?h]_+u4ҥ="Y*]v< O.*O(#9I̽YHGkohܒ9ҋ2J&$|1zKhƛyʋ8O Ps̖h(vDodmYO]Lq_3)2\z&@?Edݔ]{Uy{w9M; d |#HzjߝT X,GHP OL=eI\vqFu,;qYy s4^MX.UP,k؅Z| /̗5y"ۈ 1N\MD!PBjšp "eU&66IWSO8sq1zxW +<7y~E@ٱ˻='XN챟e ЅM[RtouX-8eMԣb q|⍨CbDj?t (.qF Zj ҿ[#EʾRzw5llJ0U1ʝ{qPsj*VWOJ)tvVZ<]:e׭ P 6Ф7glgW 6xIxq;SqU!%7=j omS/$j3VǛe<3zt,A:<">벳rz/#2\Ĕ]x0:nߧ<b$>Yo 1Wȫs\:wS94okf{&gșƔ8|WU/xZiw:QRLfkO D1qzٮHxDcsI)aPTC BfZ>kSWIfC1?qdnQ1Dx.^ryAIuLυȒF88r"h1zLŞϿNsR]@ѕT^l"yZzfRaXa _'q]FNjM3f5le %V^ʥNT2o_8(lrl.ŦB=6:Q*(f ߁fЎբQDA8/0s>X ޕ,DA2?kLu9sd_,ZA[eJ?N/n1|F:6_ciXJGr;sߞf]h<}r:1iߧ S`+N>Z@ҋ3,fb)ˈ#gyƑ7k!ow^o=mDpY =|O:v;(EQDcu]+dX8ԼO֖a1\G"dC_~Uq7b& N4\JD몤a"UĶ%Y<7e?XIb T[KyFO DkPɶ^X8DSHUGhk٠f6P( Vd'M "ّ*(,'{7t -dYQ1X ksc'gy QHuf(>^0"xr2_0BBp*J9L7Ff . Z|-Ju2[mtzSU@~EyK+J خ@T?e]>,_3v{n`rj^SbB<,E3%"Ke"JQ}UT!C eX.=Kt(w~HW-Yg eL[^g ٷ1tyY[!*#°J$. 8za%޹Kh.֞Ԗ*~>ʇ֗ܮeC1m:>'u -駟O,[{ܺ: bY4zVW1qvЎ*>7z5`a;[$Ju亵矩fV-JvWzm\09&Zpt- {ςfvvзP;k"،<8\Hn?bF%?KlC1?wF~r+sdqM[uyxrj7^xb'(YxGQ, {P[H0c=0^* FYĪuy~K*`\<=5>Zb H#X[0;ͅ,?Z=糯}5mD 4֓'(ij  tYdmک%5 3ì" x/i''G`>#kHbe C L;/jlN{Ira=aX; P[(!$}0SD_ukkx=@oN B<`늋/˒ɷEn[qR"Q1d'˘ T)˙b!edN/rЕ- J+Ҍ`V+ȑ_nȘp8l޺3ϔX` “CTpdV#G@0.PW!oR?(SHW0t̬Ͽ 0aK/Fbz7Oꍩ5Koɚ?TM.H@ %3]' (UC).JJwxL MKR`7uE $"iF o!*V[fE3 >RƼùQv""FpM̨r 4F7o+(V"]v+Ҏf&q+F !Zͯ6ԇqh\Z+jrYqq)RE|֗fx5wl55˚ >l":FoCt1_ϼwm_| 7ַ^'-t99WJ𥳐/2Manخ^~fr |Klo Sjwp}aߘȻ?nNB&uV L::GlҺI %:މ9hA#PrI.|/Db0&!máUQfW?M{*.85~(yNt!03, 6 PQȾ-`# L?DDt$LL.dEG\m<rZI2ݔGߕSDt0}npV LJ+/.$l\hS$PɟJ8a-XGlU"/OH*rtBU<&@ C~i;l2 87YJTڒF0.Y@&RNZ*xg^kr]q9M-Q/~BC\tyvDZP<8i2q4ҟn1d?fUtL!ڲMm# >UqT&X5* )vu7\) X$$[@4WJ_0ml3]n̤$; kX֋A1+DpvZޔԷH=r ?ZNr?d@()4㇥CQoHS+6W斐M@ ͼkd  {ddq[|Vn|v} 17(sY3 _7MB|C]3t}FFmL[FpmP&TExV3AUx uЇYh0n9ط+X =9կE,iTv!cfi*uѠa:i;E@8@#AgG$;x0֜iv}-][=ы 3j|F6nЖ !58rNGGkL4*Br9}CA(HAMڕ|a* y:>Lr%̣jV*&-w&g}`KJZ[V7Cz>7z@$ Ͷl߫s`FLŘ@ C>y7=Rr릏k# =1g`ۗNyi^Uss٧P4wem#7|3zwdL_ˮ'lh y}uMW2kW~4HZpPhAzo {WobSQEʷ(߃ZZv:fzȰkZ{Fٹ*V+,N}TUydnaRd5)eܔ/a cW C˯unY)/z"Mb`:W6VFՕ[BŅV ch[$?ҬKqu9`GqyF,d2/6wyP dTPE$hJh9d=`+?ZB u)APB_.u{  3}~8P2)Z*KsΥW{'_{?dKnxfAqm\Va!D&+S a+MNI؊ 烕J {{ν S! ~ z@\8$Ϳl3vZW+.a/+6#dH$WsXm|~I[BZ;e,[2@+2^%'bCGK2qKY"VxmUH3dɜA3&ӎVQ>JY}}2YCLEf{ܘnKa^ ?Zr1CW dUmޮYu8c{LgbЏ-a oxQ$/Ɠ[˿6wV*{6o[ \M=eKT=ڲ/򭅮=g<_KN*:&[ß%hxFJ` f5z%dc<-eqTc!~URohIBXqchBya?4| +xg,) жum8H)?v%dm-ྻoҥ^, vmɤ]:a+MN]^Wrw*xϾG]1o*i@|{g` HC9kjm7bcq[?&`.1׾H|C\)zمFTmpa"Ul[\ݬ~:Fȷ}UP|pX;v}rOO"a!!~bR7DwHh8=y]ͼ`쵛vN!_nN)K&LN ۹E o4EBq*H(}4*`OqT$cξ d]U(}sћ׎~=LvS}5o ;4*5ـpk^;lBqiz+!C^X憵h%c\`gq#F^#_y5W !fրÕ1Ϡ)۠݇SO=~Im:*; _ZDg,`1:\{ĥ8rjB)"9>3[J_ǻʾK{7Щh/%ЩA'%GF`ț uk[3ztʃ1 h.w~!g 1_[DY|OE]zIz_ΑS@;ͻ$EAƎvvP8 "}D귩ti.7~u2@4W=iDAԤ_rQ$qfeԝzA ) UWc= @U]OZ+(Fwj|wM[D8Nt;F|S .c0 =5xT<# =G_ZUh)zh>Vm@ws  tgrF&ԾD_MJA\>>!.( XC5?tM| Ň{ʽשD[a&`ȯuZ0|j<9&)oR{1VYU~S5I&Ղn-Z2`:r8̛fR0-rt%§b쥫%St瑓m-\쫁Ҽ`i#Ų9u hb*X .8yqVBKCۡjÇʀc{wv e%qfs:w z\U`V 9rL _zKn .VU x? 3xqCm&wFBogoިlU(\KoP8Tm"w)U_耉^)LQ!xj* hh6}Mad"Ma-]oM@ř&3rg dI!K%+.% gh8PO\?98Ga'D+g֋i.:ibmk!0 aEE{\6'حCO?-ưq.Z^Şrd!9:/x8(_ }Ƣ"ܰnO{v:n0& b\WWwYz\Aw8v<][;"l6u o zX%]XͶ[Mop'\Hd,yxC%q#$grlwWxO#ZfIc[f,Y";"U.q%` Pv,eʬ2qwɧwT:C=b2<8-;]~(X˷|GPt.-e@s9I8Nq3y}kGr~]: xI&aЏX@9+AQ B2K L걓? 4mW^FzJ\JPg}$I ے?92U,/$x C1^wDo5V^y8]OAoiA~&z}t#߷W3z-*HAp ',Ew^|oܤRd&:1%LC/vʔ wVg0cYjJ_H JnVy῾I4! k>1"[v +='P_rݧثoyf¶$i~& ;~e N^}-^X--[n8G5U.cǪ2!MfqG\fr--v w3 o)jP벢Tc^mt^G\dĈ#Ii4l5'+`>3>R }RS".)>v=G:<78t-ˣ"Q-&Jz?N~Cg'Ms1LmQ ܣ+Џ}}(E[4eQ Hㄏ:k֨X=@%6sUV0F6rW4%V3rcxGth^KQaroN@mVt2jG+_`n=T-{o/qtdYh0Y$ 1) !< '˴`:,Olai&??' oNIp]:!6v*?d 4|}䌫_xJ}kk s96IOv$hcyD}@]| M8L ;\/,;CvP[¦Y7)C#"].%Yi.ްիzQr$}¤ahE4)#Rx"V4Oia<>B˰ h aQNUѿ<8՛7~gjW71qD;"V$< 3F$/ ؗaŻ W#Ew`)ꝚFw'% lA7`Hk?P(UV!Q߰U?;4## Ibwިdx. {U۰yRšyd.+PH"늻%wxVb^צ_[7QU qAeNslW8XۅHхƈ18lR A'h7҆V|߱?\Mp @"Th<]EOe=D$dD01[?U@"F:?CI.D*`_闒+fn;Xjw\`rLϽ$sC)ˣO8I ϥNMZb-DK?rym;tagc)2(c"@Uܘ/ <7?08Ъ: Mv9b g`w{% DMa2,J9vIN0EG587~dY9)M\-\߄`1Pg0 3YpʾxƼm 2@c,ܴmSH" td+1`z_8xjN.Kvdv96· >LO]=k#ڤg$ 䍢01nNM}p._;[uZ}n_4 pCi)e ֤yv(8GWA9 Ӂ*~z(8Zm *+=Li WpTH 0pqA?b2`?xUC{=yD 0Y@m@9ĥ,\$v"/Ii2эD3Ut0@lPZ`/scjݒqKWntA paYJߢ}s֟b)<Р*3K/ʀZWFk,8`Cx۫ W*mJ@iرE p K A tDKdO"?䟞|2MDEj; `JP'E$:CDO ʣ]J=! ID=F#mcjKb"H?dUqX0;{ޛB)>p^''y6F؊bt-N+5QE9*z0RX~#Y;6 ߩ?=]-T;ePsB8t`e]GYJ+BZq_v<ν_U;s y䞾Ұfh\BETuK9ZZX:9rhzK)ҝG"!wKtXhUu+ઠ%\͸@KKݾ(nWpn'D($;<E䖍*Etـ+Ɍۜ %,U@7^V*sKQz]8ejyg錬;BWwE֯Y:RC)t ^[dQj"y1"7Oҭ62wXD 󣡱QSE].V|JDP"_dB؆JC_"iM̨@KQe.OƹϔT63Ę\/(#68ZY/}gLhk \Si ˔9Tw2mސ8Z?>^Ű?qf2Q*ώ0alwDs. H1ɧ,I)6PU&pilخC'e?6&|S"uy7o&5Sr zF'}kIWBPA>3Fu.4%9L.R: >d^N" w}OK;Đcq& }.l1.ƅoǁ8/{8[쭸5&ᬰwM:Z \WW|dZ k3!cd14{? 4Xl_O$A A !RI'GEr/Y]j9X@/ۓϒF0z7CKG"M:4Qm#;92g52U%&Cת\\oM&kI$~*ݓCH^} .RPT fo2rҝ6k>xBotf'HPn΀v ~ACdi\(,!@4+2zѡe*@.]BA Z ;bóUIc!*? !Vk'ɔEsNMMMR*b9CTzˍ&}2ŵRLі}LqxNheLmį0<'OX̚RD)Wr`z:g{ PI'OR"fQJ@*79xX>Θb<rI2Ur#GO*$~1B7PC?{H*Cz$5(U6P.hB sb1-@w!*LTt8x^tCI L~7>ea}˫W&o%玂ZIb1(AJV6oݻa.5UH`DZh?Xk+%fL-ujoξhhA7Uaa)+~ʅԊ8pنkr*; DKPu[+ǰb|,yYg0`FP5I:.;u289a]9CGO DaU-/Y_"ǍqB{MA4aLXʩsU-PC=AFE(߂A#Ԉ{)A1}ͷ,84oX&ʁ5- v }ᛆ{7&NbԴc)5B >s~y}Dw] 46=0)WP#A?@:8 v4 i*Y[Jo^&΃QO@z!셏渙3{s܇bz&8Ğ4V27M7\]=|v£]ٞ~[G?a4E MqI@a\AFЍU HԑU9&\7YFrҜ. fZYk#]RK1 +;XmH_;ĥ^w$m @K ˕=KJsA|~Y"BT(K"9p;|^79=&FwMt,JNpP=ޝ>t~ਣ& j'4e-$2Y|o o@R($>йֲ0{CEP6i_^Xr5<)iTANCiQN|s* S+#K5w|@vE.2-x9EE.8u;1wK?Ddo|G[1S *,p^?nޱ|&;kȠE (:lV $nb;'7nR`ϳ'ʱ#f,]0RkFX@bDԍJ2ps F#ɑBcFBfo}vd>XÚA(W1ϕT~ƘQٝyO¯a8L۔YKt|P=?BrH0v(Vl D2|zbFSKڭC?(YFGM_Y_م,ALs<P]dQ?maÈ@fnAJUesEk)A6IowWCXZ#AƘ n)x͝Ů&Q#F\ lQ9RP2 p^}[<$TLЧUrq-M+p/ų<))d?x7wCd aC)kq$3y.z IQb nPfIM:/Z˼rdY@b \ 3[x.E!եXNư̥ZĀeb1)P^Ovaw1Mq+Xobh/rWѮDQhW |cJm92!^ґсl|Ç"+ eOXo);>'$+/XIO]ۦbs^++XI ]Cndʘ})C U}hl֍y0,ei_;'=Ԟ;Ő齧'YlTX/m[wʝDaqq.dWfC_U/87z5JW|ACd".TM]d uV'GqWDWLQ$y Dg5/ֈx`qʹLpƁ$ˤ_1 ӌN 8ե<ͻt j=A }UkI7RAxGOT('O9OBòn^DL \ABiScQf/tnokZk;FdLd,)Y`d ݻ4nS;U7f,r'eo˔wmPHpIrN)wubΔz;4*ǐj~E#.Q6\O+?_GW>A&lykoqNJƕ㎝XJ 9CRe _ޒ1P^ jXK. c|@2YDs7~qML; uLώ-jDx/AlZ6 պY2g özơ7D-WyNJ'V dRa]0B!1ZdݯKx7j)sySg SQV{,M)?ldN"RLO[癗ut&N_כ;,ڗA ZŞTB1N(}"u𤾝P0"{d3P̎%*oD R$WQ˔!lc~@F*%B%1}kԴѸ[{M&{&i@A4q_׃ӝ zR,dꠅfF !#էT-nys +6Y/uk@(#5^$*ݡIF~^çVX2,Go2exXjZ>c)G".ʸuƸfp]Ym8vep&G^bq^lILe, $҃#| 9Ӈߛdaeyj]seDo_}ؖ4 [ XlCH_CISb43v7m˾sE1Au΋1Jzo +ےg/tb# ǧ+rS`@}&/DIs>0@UC4_9 Ѓ!r HwhC;j@m7:4GQU>rs|޹ Б^܆JZ1a_8IDvƂ˩pdU5KMI{$tnB!FVkD WY!t dg&;a3dvUUVp,TR矚WkªըX,NS5XH _l!9kVYcTBo/., G[_11U<'V6u_%oI@[8~e]躵yǟ;=ۥU-H% 4+tNX(JA0[L{cv3*!AՉ [3aכtMJ\z$ 9ygߓO#3ngrn OfC횅XcI=rx}ьq.R{£a_shʎLj 1:W +LX3C)hDA2{ޔUPIJ%(o21@jfi'|e ɒzK 2M/9 cf:C1vDkeTׁecF3pjrj7ȭx+W(vƷq$0*Amh(V63C 4s4ںDH7ϙc[9d݀UY݈;V$/pb+V`{]쾮+n `%uBZJ?l2M2\>'M.ϒaWGH#)>GsCZCB4.[ Yd9xxhf!mv=׶i^i,ev>6>-NʏR9}@:X]$8qO ia˸v> wd ACԞs-RxO_/vu#gL 7MOʏYԚݘB{~Yhe8qTrpE؝7`+9WoGD8"PO  n/{ nb(\apHꄫ1Iӥ=-Q,Qkt-~N(`p~ꈃmSၧ neHY7exXCy%ֿ[#idnYWqrvlغjm^?7BWrO\<(X;PަvW n(F`|ν_8G{Qj{^αNIer\wUQ 8V +LlcE00Vp8C(nHH]K3cd+Ȕ-h%'.h,Y/bzM{I*h{A*,1]/#(tm=MK]&+QЕʦ^E(tա#V)UGw 4v|N?ĒQe^;o#W2@dƳmT{M@0xԅV뉗,r%^I϶nR˜,|[ovj0F?p0I/ES'L[j3JUΊof$~$ZނUe6a؄|+J*ͣ司mjնRhH,'r`r{a^(s68eńM)럻~}@az|q%^j0k7tYgp/ Ȋmp%=Ev/Wߠ7J;FQ*Ag{Mo"*g0W~c92ozaW\Eq4Y]=S>& _x\LG~y.rG,Y}2$,bg_x!`a,AQHz(МA?038\3.HW Rg*!3*(u:# 69xuWTCӟELc yEA+(%McZc̦_qH "ڀ-O^6d7Ձqys?Eg M2_+A&ىY Vk@svಖpI#~'@2"cMR[樄oPXz&[wR'G'ut06:|B J??!ǔ={s0I 3w;(⦱ P@y(3b bGr< Gn!j.4sֿٞϿ|u!l #jPg_ʖ1Qpym9-2AcU5 ,m7wEZipHqr#: XEDE~ut?+\D}y 4W+hqyȷ:uZ+ ) ?,oXZ{DG; lRWjIG1 XK9j+.RP ?q ZFy܋H΍ g#Kt8ojʬD>ޜ2؅l y.+waH{Ś6fX\XܠV]ޘ:#wbf14<8XcRjP$is%tdVUrA >R|egT(_p(om`%nLx7T¢x3rFi59z(8\a mPw(SA[ L8˾ p_8aiJn- 9:Bfgj)PyEl&;cy2`tĭ w^SL97AVx^U,dY4׉"?&ExΞ(7CF-ՙA-uL4 ‴ea>4ɷ1XPH)6(&SVrqH2Q/E׳bPy 43O'uԨ\|1~"ʊ F#$lmys04Udu+ a:5-;!+/ҝ6jDoț#eTZ p n?~5+w&W sE5um\Μ|Iwn+pt”;XU]NAyC҅2~ HK'ى wT}fCƼeoufa*IGd fvs"yɯa% ?u9 dXXf7?0[d²<)c k62ϪTo|fJ В[b}o?ʑ"NJZ-=ӿJ"MWo ߞ-TޢoM +wYO#7Ul@~-8yZtb:WxBձ$"!d ݱJI;3nlXQ‡(wF0T+_,2|)Szʆc5FH (숍[J$u,-n̘杆ңYP^A/ׄ^>|Y VҬ`7=?NSsxt6{]Z7䨚@iflѶXGܫhKXo[)L+/0y'1HLSӟ hi*wg~x_`D #PQBb[;6hOܭ]n;)Kow^7\ -b3Ja #  4o-)Y!v7z4r&>1<"CLM}swv}1vZ Z>F.ܳCl^9|DIJ9ʾ-\=Ep޹gLD[6G7Ke*D AK!! :kxbp  JCxH w9'tP^atDX4> iҰJ&b00~(/6BoɁӣQ) AF7q M`׬.qq^2OȺHn$v@69Pv,/ e$+ՁPX̭BYF}A&d EE_1d1 c=!  p%;(c(!/n޶G^ če$#ȲD KAH+/L 9Dʯp,9 GB0qɊ #rE Ɓjmخ ĩ-Y ²e8s>\ WȖmab{X @ hTms*.&+5%nںW=~\N":X(lZcQCPf`癍sRyOaԂ+.z xDT&"|X5\`G]Rr,V/IT2d_4gl,}K_EPK3 Ə֥l8PC>|@f!m^vD5rG7ƭ oxk @&P̥^iJ%"h) HF{o(:Tݏe ,(f4팚Z9zc\YUk=q.'xǧ#?9|xS A^R-m&Q&_5Ex7qȳT" שy:$hG ^5xL04uJZ 4=Ayfw1uM1o"f94抄fdΣ{%DMaz){𤃂M"G|dp~ڻc 㛧D"F, mz%B,|Kg0ZZ 6!u%Fwٳw3sf֧  C A?2 %8:n:qئ1P7{nkI+kWBMӇ(@C !ЇBJӇ -44OƔ&Γ IO|e?Tb|3ofdRnW*^WdPkryB ~ mȲ m*u2ʴ%O۲8ݦ4Zv㪳VKpY.fiq?m0?h.Ks=OA|&҇x!(''  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-.9>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root Entry  FPj;Data 9WordDocumentObjectPool PxjPj_1257589472 gyJt-PxjPxjOle ObjInfoContents= Oh+'0  8 D P \hpxBASIC SYMPTOM JassalNormalWits2Microsoft Office Word@F#@_#3ABC⦀_ ,Hd+News Gothic MT#News Gothic MT7+ B,, /!!!!!!!!! ! ! ! ! !!!!!!!!!!!!!!!!!!! !" #$%-& ' ()*+,-./0123456789:;<=>?@-ABCD EFGH IJKLM%N O!PQ!RSTU VW&XYZ[\]^_` abcdef ghi j kl m*nopqrstuvw xyz{|}~!!!*C +!!!!,0 )!!   )))' !!!!! ' News Gothic MT #News Gothic MT.#5,, /      ! " #$% &'( ) *+, - . /0123456789: ; <=>?@$ABCDEFGHI JKLMNOPQRSTUVWXYZ[ \] ^_` abcdef ghi j kl m nopqrstuvwxyz{ |} ~  0 "  # # !      !!! ! News Gothic MTX#News Gothic MT# &,, /      ! "#$%&'( ) * +,-./0123456789:;<=>? @ABCDEFGHI JKLMNOPQRSTUVWXYZ[ \] ^_ `abcdefghijklmnopqr s t uv wx y z{ |} ~   $             News Gothic MT #News Gothic MT.#5,, /      ! " #$%#&'( ) *+, - . /0123456789: ; <=>?@#ABCDEFGHI JKLMNOPQRSTUVWXYZ[ \] ^_` abcdef ghi j kl mnopqr st uvwxyz{ |} ~ ! 4   # "       !!!   News Gothic MT#News Gothic MT8, G,, /!!!!!!!!! ! ! ! ! !!!!!!!!!!!!!!!!!!! !"#$%)&"' ()*+,-./0123456789:;<=>?@+ABCD EFG!H!IJKLM&N#O!PQ!RSTU!VW&XYZ[\]^_`abcdefghijklm)nopqrstuvw#xyz{|}~!!!)> +!!!! ,- )!! !)))) #!!!!! !!!!' v-N*KV \  ANews Gothic MT~( 6HNormalNews Gothic MT Default Shape(  Default Line  Default Line ?A B 9$o  \Layer 1  1  ( @@pw@nH?S]@?j@jj5O>>>5>O- E?w@`?K]@?E?w@`?K]@? s   ! k@`5?CB/   C12&"jXkdɠ0p8..R"3$4$56RRR?RR TEstabl i sh probabl e cause I ni ti ate or conti nue wi th non- pharm acol ogi cal  strategi es  ProcessA9  2  ( @m@d?x@?j@jj5O>>>5>O- W9?m@-?`zx@?W9?m@-?`zx@? s   ! ^@࿣?TnCC/   Cd12&"Xkdɠ ."3$4$56?Cl ear l i qui ds ( avoi di ng appl e j ui ce)  f or 24hrs,  advance to l ow resi due di et Moni tor opi oi ds Consi der i nf ecti ous workup and stool s f or occul t bl ood Good peri neal  care duri ng di arrhoeal  epi sodes.    Process  3  ( `?(@\? @?j@jj5O>>>5>O- v?)@ʡ?`,@?v?)@ʡ?`,@? s   ! b@n?@AHD/   C12&"UXkdɠѠ0 .&&.Z"345.6.ZZZ?ZZPAdvance di et as tol erated:  avoi d spi ces,  f ats,  ri ch f ood,  and sti m ul ants such as caf f ei ne  Process    4  ( UM @l@`F@@?j@jj5O>>>5>O- &1?@ ? @?&1?@ ? @? s   !  p@#[@ds}DGD/   C 12&!SXkdɠЋ . =!3$4$5 6 ?Loperam i de ( I m odi um )  f or the 1st 24hrs:  doses af ter each l oose stool    2 to 5 yrs:  1m g PO up to 3 ti m es over 24hrs   6 to 8yrs:   2m g PO up to 2 ti m es over 24hrs   9 to 12yrs:  2m g PO up to 3 ti m es over 24hrs   adul ts:     4m g PO stat,  then 2m g af ter each l oose stool  Af ter 24hrs:    <12yrs:    1m g/10kg onl y af ter each l oose stool ( sam e m axi m um /day as l i sted above per age)    >12 yrs:   2m g af ter each l oose stool  ( m axi m um  16m g/day)   Processi a   5  ( @@O@s@?j@jj5O>>>5>O- v?@!?.p@?v?@!?.p@? s   ! #k@b@}DD/   C 12&!*Xkdɠ @B<<.!3$4$5 6 Di sconti nue Loperam i de  Add Lom oti l  Fi rst 24hrs:    2 to 5 yrs:    2m g PO 3 ti m es over 24hrs   5 to 8 yrs:    2m g PO 4 ti m es over 24hrs   8 to 12 yrs:  2m g PO 5 ti m es over 24hrs   >12yrs:       15 to 20m g i n 3- 4 di vi ded doses over 24hrs Af ter 24hrs:    <12yrs      reduce to 25%  of  1st 24hr.  dose ( m axi m um  48hrs.  total )    >12yrs       5 to 15m g/day i n 2 to 3 di vi ded doses ( m axi m um  48hrs.  total )   Wean as soon as possi bl e Process?7  6  ( >>5>O- ?`]@@?@ E@??`]@@?@ E@? s   ! .?5^?&BD/   Cb12&"ZXkdɠ` 0 .D"3456Advance di et as tol erated Process?7  7  ( ?]@??䠜@?j@jj5O>>>5>O- ?]@@㥻?@??]@@㥻?@? s   ! X??B$D/   Cb12&"VXkdɠP p  .B"3456Advance di et as tol erated Process3+  8  ( @Q?`|@?`eϣ@?j@jj5O>>>5>O- C?@ Zd?ϣ@?C?@ Zd?ϣ@? s   ! Ig??㓠D+{E/   CV12&"UXkdɠ ` .A"3456Consul t speci al i st uni t Process00hf0 00? C 0000$fpf?? 0 00? C 0000f 0 00? C 0000TnTn0 00? C 0000$0 00? C 0000pp(0 00? C  ` [۸?}@ ?h@? [۸?}@ ?h@? C12&"e/Xkdɠ,P,0-_.."345666Rel i ef  &`?@ ?`@??@ ?`@? C12&"/Xkdɠp)() . ."345H6H No Rel i ef   `Z۸?x@?@?Z۸?x@?@? C12&"e/Xkdɠ%)&_.."345666Rel i ef  &`?@ ?Ԗ@??@ ?Ԗ@? C12&"/Xkdɠ`"!"V. ."345H6H No Rel i ef   `Z۸?Ȃ@?X@?Z۸?Ȃ@?X@? C12&"e/Xkdɠ "P _.."345666Rel i ef  $`? c@Է?z@?? c@Է?z@? C12&]Xkdɠ@;:;[.^\345F6F^^^Note:  For AI DS pati ents,  consi der m etroni dazol e;  i f  m al absorpti on i s contri buti ng to di arrhoea 0000$^    0 00? C &`?d@?@??d@?@? C12&"/Xkdɠ`323 . ."345H6H No Rel i ef  rj` -0?f@?@? -0?f@?@? CN12&/Xkdɠ003Okk.k.3456kkkAdapt ed f r om and used by per mi ssi on:  Mo Pomi et t o Pedi at r i c Pai n and Sympt om Al gor i t hms f or  Pal l i at i ve Car e.  `?8@ 6?(@??8@ 6?(@?# Ct12&9XkdɠKKL883456?mD iarrhoea Treatm)ent Algorithm)  ( C ( C ( $R ( $R (  (  (C (C (C (C ( }v@̠m ( eV@̠m (j\@̠m (qa@̠m ( ( (C (C (C@̠m (Zpl& e,   }@,~^X{s ZЍf8%F06@Eͨ؈f7Ϭ}׃8b_M] qPoL/zXn,x͚W |P:s0KcLa&|Y?a*3hZKxC9o\l;[:g4O9k(عS|H%+c}5u58 ʑàh@}m%JW B3ڡW/:u5<~rjs[BÐ)5M85 #q2f!)Q`@qc7cPkC y5xV3 ivFN#cȌF֯)na+gVC{2L/ VX*ayzyd$4axwI89RLBm-vNWOz߷v:uouQS oPl.Ah18F$Χm=e̖abShFbaʮ8n *l?;E;x eX,T@ږOS^5RvbQTlQY37>oU͠c ;Rϡ=$~">!:UPE-~샥+%fZUG:ja R*VbxHǹ=P/7[IcL/ԽHZ_h9KKz䫎Djpl=yVm ^0)2 rhH1#50.@ gX~]#?^%F=H!%T2{$bۗGqUEwk8ѽX%hu1{>یڼ>vT#pn A T$6q#[!J"$ԎHKI>C.vSrG%4ZQYHLѐCdu#?m482 ze,*>"*$\\o;6 dK$&:5"M2$<& OrBL-{umkꮙݧuX]ŕ&#krvk v -+zfgy#v=P!.ho.X{ȢЗgTՊH_Ɍ"Ǩϙ$>?̻iLQ&'TF+k-3"rEju]+P2edO܄[\veͱ|'aٖ' 4vfУAل+cM\+:HD:"P0Ì :P.'ZU#13ڈx'g=4dK^n;)/̼o?lpň#W,% ~5+&Yj:|$*rd۰gzzr-YGjzP_;>Vϓ3"Ye(/ .tzM qɨV_c}1leň-lqo[?`{GhIHó^^fesJ3Y`'C},6~̇K8oǞ:[k~:6'\U>{ԝƞiy p@;kF-!w8a#hy^6pLa [±y>{}1qnV2),dZ{gI{[֠=Fk6@&wxBW*}DaV6L݈<4r{3Y $$Ifl!vh5 5n5 5P#v #vn#v #vP:V l40+++,5 5n5 5Palf4$$Ifl!vh5 5n555P#v #vn#v#v#vP:V l4l0+++,5 5n555Palf4$$Ifl!vh5 5n555P#v #vn#v#v#vP:V l40,5 5n555P/ alf4$$Ifl!vh5 5n555P#v #vn#v#v#vP:V l40++++,5 5n555Palf4$$Ifl!vh5 5n555P#v #vn#v#v#vP:V l40++++,5 5n555Palf4$$Ifl!vh5 5n555P#v #vn#v#v#vP:V l40++++,5 5n555Palf4$$Ifl!vh5 5n555P#v #vn#v#v#vP:V l40+,5 5n555Palf4$$Ifl!vh5 5n555P#v #vn#v#v#vP:V l40+,5 5n555Palf4$$Ifl!vh5 5n5 5P#v #vn#v #vP:V l4%0+++,5 5n5 5P/ alf4$$Ifl!vh5 5n555P#v #vn#v#v#vP:V l4$0+++,5 5n555P/ alf4$$Ifl!vh5 5n5 5P#v #vn#v #vP:V l4A0,5 5n5 5P/ alf4$$Ifl!vh5 5n555B#v #vn#v#v#vB:V l4]0,5 5n555B/ alf4$$If!vh555 5#v#v#v #v:V l40+++,555 5f4$$If!vh555V5f5#v#v#vV#vf#v:V l40+++,555V5f5f4$$If!vh555 5#v#v#v #v:V l410,555 5f4$$If!vh555^5^5#v#v#v^#v:V l40+,555^5f4$$If!vh555 5#v#v#v #v:V l40+,555 5f4$$If!vh555 5#v#v#v #v:V l40,555 5f4$$If!vh555V5f5#v#v#vV#vf#v:V l400,555V5f5/ f4$$If!vh555 5#v#v#v #v:V l40+++,555 5f4$$If!vh555255#v#v#v2#v#v:V l40+++,555255f4$$If!vh555255#v#v#v2#v#v:V l40+,555255f4$$If!vh555255#v#v#v2#v#v:V l4G0+,555255f4$$If!vh555255#v#v#v2#v#v:V l4a0,555255/ f4$$If!vh555 5#v#v#v #v:V l40,555 5f4$$If!vh555255#v#v#v2#v#v:V l4#0,555255f4$$If!vh555255#v#v#v2#v#v:V l4"0,555255/ f4KDdf3`P  C ,A?foley pegRKk]-.I?pgStJFJk]-.I?pgStJFIFC    $.' ",#(7),01444'9=82<.342C  2!!22222222222222222222222222222222222222222222222222p" }!1AQa"q2#BR$3br %&'()*456789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz w!1AQaq"2B #3Rbr $4%&'()*56789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz ?jn_b \#JTdJp'%^?ןןv'w}R'fz%:X|i^G y8QHfwz`~OOtCГG3O%pdi?.^ Ni}0iL54揪L1?o7O/\Oi&v 1M>3i?1\^p0.GQj}&V')pWq&>O{y;L?e2?ѿ%?S}EC}OkOz\揫S}η3-?g&oc O uɷ=?P|g6xO({3Go>R|e6?o&wszZ>O{y:L?ew\;ќu⟰=NJ|cwbi^(*$J?Z=>t^㈢h$A4{ }Oߞ)1X9"cO{Y7-{cHG|C]S?Xcd=;s]IxE'$ztߐxOð{Iw5OC//HLg_~vh1ɤc@ t; uzbzby0c;YJ6J] my~L;<ތtl+)z\D4Jzuq@<)@ &8'Hqf^{R\}h )jo\m;vZ^&u>(qs 94` 'Oj\t4L( &1ގƘ z֊ ހ!88zB09J_43@ )zqB}kTU1ṥ9Z^3I@ZSH84 o?z^#J(4A׭.8H{b1ڀ hGz2zҁA')R{ Rҁ@^Wi ?yR#ֽSL]r_\XՆ\R 2|O I~k.e:җƌ| qI83zA֗>ߍP J2(\c8=@4 Q$fdI}E)4cdPӧJXܙ66Pb@s߭ ʩnF0-&STV=@v`f$L&& !y"b.)r:#8 uc=R:T~fӵb~XXswLn=ʷ'qܞHaI'ˑIWS\C/*sW*ml-Zh`Jp~f` dCF?:Lbo;Sh~tg'QۊN=QRm&@8G(C@JC;!t@RsFr:Q(0;P<;ގv(S4 ;ړŽ(=h/ Iץ(#ש\Vy`KHEr_\xӆݗ;4S#s+#ğb:0DŷjPv9-FIwr3R} qIE ɀE}Q2֗=H2Sp~aRL)8jeb.RwdYxaz%G$6᎙U>D㝲/N1NÑzdǘ2={=aQR(~h>pycҺ#.da(ْ(+(#5D i'~8NԸZCAڗAw8tM@RPy4cQڐyazR8c'z('.17&֊\q@t&mJC44сu@ G|J(}zΑi\W9z {Oʸ :p۳C\`Y^"D+W\}t4EOw3>484LI֔N'&}i 4t4q}TPA(IȠҁG@=sF3=˚Qb)GQ@ 4\@y; rMI z# 5%Tzޣ9:SJM\JdDTcP*b {r1p?SC7pk7xHnRhbq*b/jBɗ2w>+BQUtgi)qƴ2i "+u& ?z gi4ݨneO9݌S'3*%M2$`ר5eB$F1Ս2vS g7Fv4SRܩ ui:@ M/ZE<( c/^PxJ: Q۽z~sZ1^akӴ2?m?똮<_Ž6n [if3\jh, Oұҽsɤ4g'`8AtLt8(=M p#QZNhhA'9<Ngh ($ 3h@ 3 $4fҀ=i3A})qfh#qIZQҁ~sL,=xP:|#ˉ֛y;G\sZ\8m٩Np<#sܭtk ]??pϭ'bsMc&sO4{t1=R;Rr1K@ ӥ/8f0q)擡!Ig;ў9LiA&/q@ Ngc(Gzё⓯ ;Qq'4qc9y.dk AQ3lR{ԻՑ^F6dzv̶4JKwhHxh)u"x4@n;hAgڣ㸥zRXpE&7 p& >SdћyjxCzry>k ?JNTˆG ׬,7hNNG[fߊkxI]-; Rc2Dhh#֝8&@ =gZL\ qҗ4 'FB!<)=jL3&q\hHh=}@/#ּ}k|:s[s'(|LZAK^y3 _օP3u\T>$),fSOQN?{i`#2q֔ u=)^^◠8`s@/4Z);A4@u(Qz\4RupQh:'(9hOi94vv@2)q{Rg.=(8=h=}(%ySB(=i}? )&~lQJ:?CPGwހ8Z;{NFZ\ΓG$8@ MJS@z$⎃c4cGJ1=3I('b@ ۞Mǭ;<҃JN 8Ȧ+y_+rp(aI;_#֣xw )Um WgYoZq$L}E5$ ;a121H1i◎h(>RgQ@ ; 3c)=1ځ(h~Tw!s@ Ӧ(8@րŒ/|C 3ҽ'k׾k<6CmCrbta&k)_y`XĦتZΓu\UCB49Ji0=(0q@gҗ'ZLҗ4c@ R׵'s@ GIA1@ izRgC-,2cMǡ;S$^]Owc>IԣmSn(z2VQWWEPݸA:[9=8}swQ)J~)(@hc4CHyc4cΌHX/b#қR(1T^B}E΃տrц)Ԙn UOK?*U>ly'sґ^ sHzsJE&y :A4t9 ^1րS{Rb )p(ǽ!8t"hz\=('8{R☋?u}qKnqGր'PG((iqNh>3ޛ^qQ`Rd@N;S{u4h'2A4)^8!sBE(@ A1Ҍ(h4޼Rs1Z;Aؠ: (ǥcҀ{bրڎ GQ֐uOp:8i3ӋgZJPxQRnX/,/ܾ㸬T0ڬi gHtkNZٕPƚ=jn(Ι5J~qF)I_z=)I@ v%iN1CӞu1Jq(݊N(#R=^Ph?JAIדAI1Z? g<7</ 3uˋ?nө(8z{T6sT?ʜwDcyI׭=&`֌@F}ҟz@ ܂("y?ƀC混yr-!Zv(jfᕶ`Ƕ)Aam%_U-6]FvP76+eUd.ïgGZG m?QF9Q!⌎4fGrp}}?*@xh79{G v9H՝5x"Y7ag _UH¤tI8~L:VhBYmg8!.+.3JF=~|Bkm# W8OXL=i=qAuJ6՜!rjeZ:wĴ9ǜgZ:8Lwv=jC4sI44hq@ޓ Qs@=E/Z! ohw\د3(&E.x4Q\y??ʥG8/馷<0?RK:O,8&zњ>G~=Rc iI zp:@v^zvF2()OjAɠ^qȤ$瞴s9~t_j=PߎʓJ;Qq֓93@= 4gހ qKۏғǥ(8"P=9&gp@w'^v8&8z@( \rړP!WqRt<яnih3ؠ{!1֍t9h^(9Nh'ixP sRt'BZZNԿҌO^M0@=yz`qt@E41IP\ThT^Rf:zIsĜ|Ý*T!Q^iA"壐9L|g絹},j:| .W=*ؤЦFN#5f=A'uۃDr~KI%ԕ+sq>czTFk~ b:P I҂p(8=zKۭ'A@='4iz;H:҃/9a43cf^O-lI4ְN؍Wh9:qM=y r8ɣCGրh9>9ќPOSIJOʎ{c$Qӥ'=(@3Ars-O?w~ 9&  0RךvIOҚe8皌 ԓ J?E3<=+<:FHR4dQu4qސg`b׊LڌLE"ւsۊAJLKrAyz2}(^ڂy'#HHgsI[q؟p=r1Wt J7 \/'Vn/2sڃ299|7›rvTvIVj8fKwz9ϽF\mPTI!(&i~ɦ)Q`\(4w81Tzb4RN@Ž4t8h⃐֔cs;Pw~ L _ҹ_7gP)i)¼øpN4W8įj/5-> >c#i`dt&y!XLq\f :?RH"Huh0< ;:PNN1JzҀ1)N &ܞ4GxuCtJsv ^cunG 1Uce| 1L C7 gRt4cbj7[nuM`c=8i5fy];Eg+׬MkC("SK wX9Y*P˛++2cҢfc$9%-} :Jԛ2F{S֓LO^ JNih(٣Zh)O_z^'R2hP103N) =h(sH1A?=(' Py⛜PM<7g9'uM㰤!qJ89(΃E;e<Jl Ur q;ZPsV/98;YlL'ewsYh*GZp89)9ldj2E}h;(֌t 3.q8@=:sҗ4 zϭΗ(=9无hdG%Y+$#|O|gYQMJ^)C@,z}rzՋË?Ϋ>-1qM!n)vO˜{t#ZoJL8<34R\A@ @At4i;S$9Ҡs›iX\0kb%^eUTN.qwGGZO3-1?w,LrtMfwQ ̾n8F3WVNLJ3?t֒Yȫ}pUʬN|S@AE`J{lW$wRi#ԜĹYGO/+:.8$2G 0H 1E~WJ3EZAE+6+!J/ LZ?ڻ֍\t)ՔN [I"o'"aӑ]湦ڛ9%Iyڱztk{DqU\V4:5:j9:R3J!'8&g0}hR0&})h 28Z\ ◵qG9NPNx4)O(֕JLqFM&8@ )}9#1=RH{Ԁc jݼ$N;z栍6A27AZ'6͒ 5I]B6ԯL0 zMW\vyU4f'ԕD4q43@铞E I(Ϸ@ I׭)18)=ydRchQ׊(c'j^rs]\:] =W>'lڇu)~)4-gU 7qΫc=㱠{PRsK4P9h=89(J_Ґ r('P9M"#9`i1@ xiw:cq@X njP2M\&eoj%.TTUm-[~ǘI5-ꨶ>ʵ*7.I+0b99Rrzʍh c3+nׅwu0N:Tsq4ܠvsnu BO̟kѥMYU&/8{Xb B|L.>a?T\m;OOJN/ZiPuidpM)>hϦ1LBqF=(SqHp(qK}h΀;QP1;.O s@QGt4RG"2G'N3SK8$(ހN#.31LߓFZ4$d|AND!ӵ_HVL3^'V3}a mO7+>yB< Yyߜ?Za8[VD(SN+S1/4\^GqFi(z ?ȣs@)g9F}F{vN۞w9 $u4xu8']?Uq]]WZNygy5u4#op?:C;UHQ 9Jl{-DRYLfq9lpx"LB/%TnnzRnl"#6Eϰ03M?U6:4[.ly2asʓj]KVR@9=k?=ysQmJKT΃iHWa]HcwǽKk,^B$FQ0G;JTw*5&0!üRj#b+qI"e-'gT! 4sޗ`/~:S>1iN =)Fpi"NHsF=u(SJY@1Mi M&rp͏e5,I!^jDPlӹyOǗqS7*^@x>h;M +s?OJ,pA'$q0KS9N#=i ?ZБA8-\zRcJ;Q#=A8 ri0OCA=(A1(>d \⎧R}zNG~u@ rUc=>_Xbͨ|hiWw)M=( oUxV\jzysJc<Ǹu }zS'4P^ ֌q A(=zkunnKҮ\+Ļ_Ҙ[J֬bE_4 RK 4hfWw$"ڪNFG5^>x TQJĤIzRe.c.*AEB>i75FycF?ʣj:Sǭ]lPO4b34:.sFp9Quց@.;g֎٠gށޓI@ O?jKdJc֓9RT~yT 'ƛE{&F. XʩaNy$fLI(as7㞼VNEYD2K4r3>'ArNOwrI,IӸgN/*A$KeG!^(NHVřKpR6~ I<`M7I'G2;!US\dRqz^]z:t>:1%v銴:|" }G#*Qv8TI*>‹ͅ n:igg̟>wwirI(1GV K%3~ U*inK!RzJBI<NADzC8!& )J01@4v4nEߝ/^1FOI'E.yi:{JFxzbSzPs@ /9g;siǑ'S.0qqH8b3KP1Av~rM=Z1]_Xb?h|h- ;Ju405[Ωd*3-["xf;#̖`樑 4n&rx>ڐJcӽ8i #`Gz"\K SϥDkB:D?LґpSڅm(y!y2;RQ4lw'gGtȀ0=랹1ȮSLph S'WSL LTҒ3L\֝/^i2sҁ }iG"hGS}N(9@ڗ#|P]iFj^J\I(J]Gz ԜҀ}(I9v[M'֎@qI$~T84g#A}O=(L$g/Q~QIg @&G44q9 4ڀ8>sҚt8'ڀLb<@|Q})7wZ`8!#gsI8qȤg׭5r>R@g<#IhϭJ!yAH~M׭)8ϭ'Z3=hKғ({cn_\z8x}f Q)uygyCgXTWlݓCG-q4(^j94pGzN-&1GJ8` c9p=iIG<`pAJSu¹8֗t֥n/CV%-+&yKnlpiOHTg <ʭ '@f+TfACLsK:U'zw#@*Qy4g=i=yH8"t>Ҏ{^րgA(:QI9g(F11i){@ӥcސqޗPӡT fʀrzO4)QhJLdc/qtA'Z^3֐))A>iFyFxb8))sJzsIh#j QF: 0{sHޓjwQCL8( ^(sJoF2q\J9ғ&1ڀq@y (tH{q֌{Ru8st f9]p:6mGGp9.k;/Z1@a]5W#j.G j]?u}שQZ+{z;s]!g(^87M|ӿ ]0>g:Q7L"q >O{85ۯss'/!v_ҏ}# |h:) }fq )ǽ),笴C?/KTLs48x>ûJK~F7Ka&p$Tu|!){I}Qc#Ez8Ɣ??Ri?3Kpphq^<7u_ӿ??Z>3KKDigGG>#y"z?/RaKqWs8AR&yßi}n=yw<1FzW N)]!\a}Z],Jn8ҽTiv Ǥ?̱H?أq?甅 w=AUmsh()}q՗sx4@s)`׬m`zQ>N4}@˜7vw <Dˌ](s-{.(cr>\P1KҀ QE'Ҁ R(1F)zQ&(hZ@)qGZ?*1E-PR_ƀJ)hǽ6v)1@ 1KLPsE-4J)hhKE& ;PQKE&)1JhRQLQKE'QF)h%s@ =BSǵ/z_ƀ1NE(Z %—R=N@ Kъ(Dd33Z  C 6A?mic-key buttonR?ro4;+GCRFro4;+GCJFIFC    $.' ",#(7),01444'9=82<.342C  2!!22222222222222222222222222222222222222222222222222P" }!1AQa"q2#BR$3br %&'()*456789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz w!1AQaq"2B #3Rbr $4%&'()*56789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz ?p! 3 i'z^ݩx3vx LњJ3@ ށA<98h )ހ())h:qI斐j?J`;9R)3ރ@ oP)iy:сAL9ւxNJQ/zLRy4٣vhE.ibZ@x84H=(ǥ8ӭ0q`Cְ66\?cސg%ܿgki@ֆkv z=tQ8/goiHڌ6>y%=MmEasz8(&` mBN 5a-K{8O*ZA')Aok7@nz <)I ٣|j/ʃc?7XƏi q:s*?[99>gEAj[xTږW= GoAЍNۮSOҹH'&p{d'yqP5+N ?PiAhQRhQ4dG{$uZ_/\4G:cW7\Po&I9=:ynF|~o&OιQ8hdV?KB<ѻR#'btyvu=$[3c4|8D_ι$cMh=?:_11\v8Avw`>gb$CCq\w #֏1#ޏl;,QI;̓7NJ l wW"nf_j #kt{o /Jwr q[۞O>{o /׎ȍB"gCZ}AY֯N1\XԮy͟Zyg[G^j]Tc7qG]Y4fo{-)yQ`,h_j7ʗn?Ïvc#Gs?۷YлG?9JO&h9gG=qJ0{szwʀ3E M蹧o\Ml2n#xϧJhw/4!@JL{V<h p4g9NrS R\((OZ4oI` \u:OlSZ?o `F /0ny? g-lzFIh~TRE4hwd\Bp0@? weDhcwađ.:U`RW \dqx5k Wp'm`$֞Zl9?ggfi%N1{ERL'i.eaV{}G($ cW`B@%--O}3L2E%圃bWOJֹ7fo^i)v^+2У$Qqڤ f&2 F _ΟrEa?sF8w4qҏC=3ց9h] `M.qғg4)N:sFA^.pi{b hAӊr3D @4!)ߥ      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~5)*C P͹=;$ch'a܈gojS<}I9 j,Hd`gR֏@z1N;>)vP[hiVMu:Hl_`:Q>/kj?oڗ4GJ94 \KiG FFbx[?u\u~6u!lciN1M'8,3zRZ`OJ.ߗ=iA'/<h@<8֎L@KsGj SqyPGT1>fE]1e7,I,w=I\mG=+4o/#8G 2b##MiGpQU,dJvI<ҳ|.}Os}*K``dU8muf87OwՇgL٫!wSۏjˍ/ģC߸?zM-#r:}*K]nc3M6:l$֨Wic  k0V32OnP[ T ;^R7eS#FqXj0l93۴WqO[K$,(8{v76F ȋxV=JPBDW "sU12Lv$Aڿ;AmaW:ʰ\7%%ی)Z$旵 ԛ td9qRu)9Rq:IyS+csT 1N fI)1 OzB9 R猏ƚKp:>))PSZFVfXc?{v&XDZN )Q?ZS33.TCw»cNM-ԗtҴ5DȭxGck9W=}:vs`M8KH93s@z]PXoȫta%P?CT¯YI]ERoJӤէE•C= h*6ccB (3$!ګ% z?3SÌD^Arv*rSWG?LwV2d1m˟QuK>5i~gT ]?adVRPyx}kcK%s!yGL~c{GR< R;ONTCo,[Wmҳ Nyм'-M+>^-gX@)n_j PPq+@~gW%/[q6?TKfi.ziQ4s\x>ʚs)xs@9'֓R Hv&'Ґs]ÐzPs1ޣt.>l 8t*ց49':1ߚRyۚ\A֕@ us֟i1y#ӭ!(v iF4(8hwfuSqF1MR>?阨͎5(1['bTsȌ#iCtosM&A8.C[]y^".-HJ=iyӊ|Aa~"2@nHzo|@3:?;i< yͶe8Sf\׵l~tR@HQֺm5w'1?~31ֺ/vk6N̕z[]8ٚ>)nPHSZ/}J֡g"5ْ ndFpxj蝙AW's׍c"99`n!Қ#d|m`ZNyr{M4 ́==N2Nz4я!.AA@2{Jh>dp)C҅9̒ҟ8iF})1ܜ)w&z~tc!A O܊"sH_\Ӱ1ҐzPF28收y)\҅Ͻ8t4ϵ \)F2;)'HR$$Tddn0t2(s5X(ݮXzk(jYRv ފJ)H擨Ji?dn5.g?dwɮL"Bsjh 㞙)>_җ򦃞zvt!Fs搐Ws0&OP34\Ѹqnsކzދ n:ceG#ѓ=(d'4"Z-:hݑ';id~:NMh&mEPXeUM`tEl7"6y J(F*`*I52. 1TW=>l{8x8jB@bsNG@0#YhV"ӳGGz>ME{b-?2?ƥ9==kIc;q4I`ssHbmG BNZOM'qJpz7sMDn0?w9y曏LRe :ux# i9T1$bF9:RIR s@^ڌ;֓01Ngc8A4ۚPFy~$sԚ4N3;~G BxgT\!냜ӀQǵ?4.xAz<$sJp2zQ;bq)IQ֗N}hǿgZPqy44s?uv_W-]]eWbn)xK]֊( J1K&j9{Md`ya@k0:pM尿9JXsI.FFi);PRg1@ni =c٣<Lb۱gX, f q֘pڧX1ւV\JQ5_sIyCph[oĨG?f=0?=XăU:Eߏ oy+#m"{g17+ODyjU;[=@& Us˵8Kr`i2m@5d縤['\jV$ p94XҖobG!Oc<7 (_CB|zqKU<ӔT՘)8E~4n?Ҡ+^F(F{Uac,ygJIlEzi{+'ZBT٭ʽ*)-Qd56ïi6`gvR[Rp88?%y&T`prMj=!eG|=BPHgw> TlyVюy $@]$Sd֝i~0Je_FJL,Dw)ewoi\||{$fsU2*pQSԞ]h l sjkY7rD_9;s"~1v.Dadk~)ץV??J1>f.Tbfk8W~c?\5Tt4عQOu' s}l}v4#O)ϛ_ձUNge)Pyjjm \NJl ?ɇ5jkx'R&C JN'yy o T{f~BC6J#sާw)g턎sI>< Ez|Mݸw 3Qj[yV?½7^*c4jNiw-ünms{8HmmUܟ֭Xr;bhˏZ"dkw8$UfRHe4xyT kvHFۛ0s@("Ƨ$O4m b5;k!>zQmoy9?\2ٚ* sH͍Jn6 ߱I1[׬$.3L03ޔWne8Hygғ'=1HA 8iӽ0## u'h#T0M4=WI R2`Pm#K94d&1` 9)HPyΣ^9LZZ@q(䑚Q8uc>lҏx@z-( q4rq(9J\ hC@ϥ<:PsA]?ǃ"O]ƶȒRsZ( Ɛ\B2*qZVʳ3p+CZ#bps ּ|L(Cлq=班IcՈp99{j~SS ‱`n=Fx8Jrzp)b@N:~ԀC`qlFN?Z%=}$c4$1jd2#=( F?M㧽5ASԀ=zSBGzҕZ\`+*~) y'ڝsy.QJ6Ip{Ub[%"]v^Gkg>E#%J.)skrcɲZW^Ylb:k u#1Z*nd4 S 8l3_i.cCȝQL{yFҞ6Ikhԋ2)!P}>ʞsywn   ~fc(A}Ie$PIF@?ֵ2D>0+nǽKWw4zl~Qa[\#帐fF)KаRm-Xy,DsWq6ַ`m xӝ5lpj-C­4jQP\sPZs8S=J^Li3? d(7 eju—O4aNw{q]tZ:HAR (\ջ-/Kgݟ1zf+[ض(9ܮ](ubzGVgʳou}&O0@0#^O}*PS3E*̄+qS7S!ְ'{Y&Cspv{U]ZD^pT'Ν@Ŵ +Z3<ڐ)uzbk`jD9Z3ՂPbq)?ΤF#$v08dҔqHt@X^zdr9Ͻ8OZ.,4FH#T0T zdztb:d!pz2ansǽ AGVP05D4;Jq֙zѸ:qX\TL+z֝ÔR8K{SwOh 6ҏ.842i13(hjzXSc-कҵ࿳"9irȏ I3=#qTIn,刟^Eoj֙pP7C\ld +T3UnFttSٗBu)rM~^#5*Fcqa@<5[~Jw,K)ne%J/Gu;*Ӆ-Ƕ~aVXmGp>Q#{br1Vt XKRnd6=T[Hr\դb?m ڞnT z`^ْ`v*?а,)pNAggsXMc!d7qlR[JbÃ.F! m'hkDdu RCmgL8!GDumM xKYI N}كNP[覓˶纜y8T7v jz7 nle2G(x`~y4{&?qn&@B} -3z-UG՚L@܌:wS=1sS=BgҜ5qt韯^-T 4HB?dO)u iQ>yP-R6d0`Ti> ʩQb":Ԕdw\&`+ЍjRbBM'"43*uϽ^Հ:'ֳ}>KVzQ"8W~SARF$1╇pr1s֤8 Fq0y敂wҔS#'&O&JH$zrU*CO8 $6@Ff+s3OSgQ XҧdYf\N*s}E2mqLLx'ޚY#5}H^(ZBg,#|`=7Ω#dޓj5weN.@ȬVvL }S!nfToqI+xH$X?ڔQYFV=f(eH&s]6iܚd !1*9.N>p85lkeReC~XiDkMBdʚ_S# sT滵>mKаQ%󮮧r9$3jbvQ$CTSKSFu%%&p2B\lp=b(ICk=VXā\S9(Ac~Ο"NW pj5=lP 9#iz,qGly!fUqLWLocqWн"vfv{TGG#zoN[89V%;9eϦJ\jUOx{y@r[},R<5Ym ZAmq`+έR đJy K<9 ͐sLs˶aj2+D˜/ȤQZTD׈iVT8{Ԝ~U2eTN㍥y{Nvz^]6J 2D"WnҨDzB>?F8ێ*1 sЎj ܽsy#ej_+D[b~k i#tP0n9O+͎5B`$v&Ȓ{r2y J )y=$QA?x jF:HIw5@# $2)c25cwl 1 vZFw`VNM@q>ԬpѨy Cm!8-p۔!$Zx%TUA?2Om1Bdh"Y3[.NKO& 1Ub1 E\z ^*J$g&?1Y'ֽ^>~9 LvzDGlZNcBњ:tCH bM=3@7R?zßV$~SWUԮB30]j{D떮'v$)Urx GjʓW`G84߷ șgOST'=y[jfX3imRE/X1@T# zw(ΣӒM02cT2Cn3 `r2dcG j΅* 0L0$~운#@U-R/N Ik4Tӷ|4f}.b;yTcҤO jg#ڟSՃiV$xTCkyt 0M#'$(9/{ht_,u`9C@Fe ~4-H ޥOjJBe|I0\ѰZss[f 9\d皂Y\2T *,YLګn`34gqe(|5,Zɲ_M&UV=XT'Q)Py'ګeб V+oh\`bWr]p2gw e*õ?gs/cI:pΝbXyHGo!Rv@o8aoH={#9vI_$ 'E% Fi1gT yX6m#^dFJ⼄zWviĎ'PbbTw,Nr6:[`+ 'ڹD glNyE#^ R2Ua85EyN³P6Oj$u*t[̒%?Z_x@@Q+1q)ps>gf䁴0?C^:Eru9 Hr=R*%2wtN3I1eR(;O^1M630|W<@ ')TO2SQIAUgt 8 T~J:d*b,(ŋW\''H#Я\*_~,m",sNE٤aya|f1`ekcBҠHƠ pȢ5?~y*Q.gAm,v|O=#]F8cWP 䊐 مVJG(eBU%V$#.rHiӨb&%ފ,@bu-6IZ]/qCY]c6ʇviHºUC'2 HbBwDG?),8( ۃgD`2møـP +88?OELm;c>\RT1@gޟ+L cbMA,ct7 ;LKeo݇R=z~.'!3:dn=c ,luydJA*F=NqڬF\Gjwi*.')1ғQ_{So brY'[ 3f鋙bs>AW'4QN?T0)# +լ]dmfCd#A4͆L~IjgG\qU+GYx֛jzVw9 ֦TAbl;B/Hyv6RE8$j,,%$ r{Try8&4;?:9Lj/,dJZ(#=:DEI>cvk:#Zhwcg+1+3iEW#6@;O)fPzרriVI$T)# [F9M.7)2+HLaWps]'x*ol$uvy\`®D x{T|}.ګѨT5}2; JJSW=1Y ojS[Ŧ+kHUɊT2 3ֽer@1,mΡ(:xvbg7{\ԙ%.i3@3L' MJpi84̳bKUIUd;#!dX{W/hN߻<.cT2I +Smٖ-K.xQ "W|;ph!qy?LRo]̃,Cg>٦1;N66mյGxSNߟL] cLo:8aIs[%ߗ]`NsR7iA_jڻ]A ж1Op)<6q08'ߥkLnἍm t$ugp$C ==Si&`v2;F.{yo$j '!RdAp޿ ym\&f~$ k g 9;Ep i K3NF0~M28*rZl88U$2؈v8CvWb 4{)ATJ*KsΞV݃}G$WUl}(x#-+UP9̍BUP0sOIV&%E皾 G41ܯV}}ii'mZǸ\m"JBqR+,3gsˌ~u-l?vɸb)'m1M$F7Rs}UuCpm<#lRK {s4*nmY@vwuZe,2PzuAAGax~$ue6z x۔}jʫb +8EBz5;;G?k(l;CusT/4|̉WG uA6>niD`Ӷkw :Z17ϭ: D lVհ# /")B[䳏Z{F6rm Tp\TWZ\3 Xu9RZAՆM  wx*=?u#NjRgrF2i+NJosxݻ;q ~5<ݹ* ؕ*q*K3PʎMa'3ҥnDU#4q||{ʧ*W{5Mci|x)\GYy G"q}CbsXasu"X#J=HqT9fy Q$A ;5b;%_CZ5898ٽ qHM\з19 ,i$iɄ1 ?RkE1ŰO=k<"BgB9 P$l SԞJSUOC՚V!IVa* AAӚ&L =, S3~t 'UyD۩"5,X;(dAц9ܱp+MQB~EcdFB6AiCHzyG`"LΣon9r &3#410= p$0> hF-EojGROG,#D< X+& YK 'zO-p{m~B-Y@--QDa%<dcHvC'ڱnCȣu4p/O\CLxZW; M_\ԡ)^E*du~fC= n s$p: c˽bÏ0f7Ofϱ3 dq"a%AǐK(݊b + 2 3FnfH/6q(?4[S춑iNҧUi0ܫ(svN/fȻE8n sڮ_gmk %ʏ408KqMoޜ }nA>cE,$ 61N9}}j=+gk>tiv4AB:\^Bp5$6X'=Jo@]"S=Z{U3鷩=1h-smHRF+pq0 `l=*Žwθ$x! )\-՗8c'ZqA$!ɤ1ȯ\@FhwJ'sJFrz1Ո8fSb$;']=jC!v2}"AH)f($icD6i[V.#c'$Z'¸HvVg=^SҴ0]ѫ9v#VLG1{t |&^qڨ؎78-sǣj񘯕l,j6FpKsuqvG BmPZE8EGRzfPwcԚ;8lN޴1&+ e"U=jII{\ [ @22K 9sMT.N31i6W#8qNfѰM.Tr<4 e1iu ,\u` ,7 A6`|EXQRjEH3ޗhcځ>ܜ KuPк"2b7HhHg$bd)bjgg$č#cگG H2c$Dw2ge Ȫ1\m@ulb3ddR;{ 2jɻ+Eq5#La%W:Q"@POB0viUzCaF=m #IR3م6A= mb Zh# \OO R@pǽ8}Wi؛Чiu[d^%/º`6vϨ dg51ASՎ#vN{Ss0ڽGl E Y+q܁3Ry uƜU8ǩe!Gn3H4g+n4 v=Lъc.cI"_CHF2CK")\q}.aU?aR263咠JsR?<=0w<bB q4/*G.})0ZYDS~$+S]vP cosJm`٩Eu4}\\1TSE~W TXHXs؞MgZ@ЈUXrJFNcBM;1a!>:`$nnqw zP-ȮbY rGJ-QX0sO漋|v/O^MYpDnjw{M$uқ1ļO;bqSKrHIq:I62)![w[3WmyYbq*hP1 += ]fFۑ,x1Z6Q2ڹ=8imXY 6̹U,$+R p˞96@P'+@ ͺCarA"cevPH AgL޶LToz_(*&\fѓWqGN94Jc5@ifi$7S4lUރ#i%lqp@"#V! +$bG^wLa >&§?-*KɁM#'"=$o/:xZxw4Hꈸ@Xz¹\y+e! ֞*zQ򦇐 >I$?3qjm/"nlA)YI G+hx,*RU7rlhq Yަ6 fR9'֤1#n>3s~9R9jHX.r} ~fe<[+,['^ɴDA溁ҹ37d]0Un;86)Qh*98ϱOG)"'籦.DasCHӟAAW%q}~s#G8t !.H#֕Gݾlevwg'P`7,P#i 9zDƬ;wd&($VfBݦF*docMK:ԗ'eh܃ vtϧL{,gmf@S N+qdžxsr1Ri,g|hxrKX"M8P?=PYZb[=Y>](!b$s>2x ݉ ۠w7҆$J7(ϥ##jXMIV;^è ÿ m.pzrjA}i~<40FJ'# vM rO4)%rzb.v.q:҄m8-qu&VvR>B/ Br tAY@k7?_ZLi̎e@^@L7ڜGﷄOAwv4H8v~M]X{5Y~yҩ QJ>}I'Tq7DʜG4G"'ndQf[vj8*֬M''uąkéǛ:/j}E$<AD|?0UCgls.Ip m9cIӵgYH$PGx>`\*u rvzq@rG0'暆,,-FA6>8`w7h'\Yݰ{sMP~UV=)BdI `x#~I)#L}iPDhN3O s@qڑT0 {(d8p1M*NKAC ^)s֑:r8SQ Ͻ!0pzp*A ıNU_LR(V;!pf3*LH^INzԏY'/,!}(mr/mDwq9`NHVP/ IEރ9U 6LI#Uqӏ$q@B>T&ITP}M4r!)rg4Ug-vW1kRcӀ*㱕M(.)%P",vF!siST{^?2aL'HO@) c,uĖX<;0rF72ǧQm*9# \ OOgsc427C?)Tc,7x'C+x&IN;6m|F||anH4'4]Ͷ.{iѪv:[!wYcZNron1Ri[t=?E4dQ.B/fAIlAԇZN=\PHRcLw+2qҪ[N}?IiLր,I"֛# BSx Nn$6& 0qb̝Q+[L88}&])2 tҩvb#G#0ڨ~(ӡHѫ7atޡU:FET>NrqCSEq +*:UQGNH{֏c.?Jd9ztG\J,.ÚWT7I5oca Y8س:NÀ+)T$Hcȭ fyf`PW,=?tp$dSU)昬 )Ypмw83} ' j]-@̸p*+!\\lG9lcJr\KJ\Gsڀjo.8&Cl`H~{k6 9'`fQJ9aw1V!xP)bZKr!FMGz&Bwgڨm jB p =Oc{I!Ersߎ֊h-#pJWzSikBRQE#5 ?g|2lZR:=99؉60w'(WsJez .0lTzԳ ̲GɤBe֥PA]4D@ :zl%vc3Ib,qmnO&`z*3?vD}ƩxcLR;r$ ̍D #ZGğ10sCW~9b|Hq{=k 3(pm }G?ڭ0c7 ?lubJYWNwj RA[Y#jg|+^M8⣐0g_=35VaG"]GTcOr}A⢺x]uh?Zi6r)0 \5& :^sZ~j#rIzv,<{f]i 3ڛ0: NS9l*Fp=(wg 1k:[GjVMRUŮJ ao5LjLF3+5uXxl޷[C Aj tR/BZuI*M=BKE9J]pӖIwN͗emGWng&l2~3k''JW] ^e;}~`1>pV1@dQJ8In<ӣՍf.pO>^+XVN=,9^@49sYh5M޲3^R3(=q.f#lN;g\P4Cz`cJ77lgjsjP0sY] W#U)PI^98w J߀ :p[ `t5+ǩ+TbLI3iNnqo *p w#|'q"ߥ"`I}AZ'&#YR@Upljj>(8#iGA\HqqLB8.=TARjN>R $$35&e݂+2 Ksǿ%.F<=I>-v؂fZ.->~SK8=4R{g-j`@9PŷrYBx)ܐ0s=dbl841RXAe޴RA-=w(;R2$#!C` J8w@hcH<~ҀS)XyPxP-Imq߭Bf}$,h͟lSǚ|4av:)BN';{tU|n)HpsH/)8%Qx#JC;lF ʚ@z)Uh%qNmEEV`ÿH UjTTz TW$y-HrZbr8€g'$Myr7JGtW@OUU#ޅH]8ALy+卹9^e"Fy5V\Hr1+_B G+4m1eeQJ{wRLvjΥw0^!; }x70{:Qsoq[+[h&1gR^A^;a#33Ln:m0VF2v\ `_`yF_'#꣞1XIDh\RjnrFz)BkIwo-2F9>-Ҥ%; /u&O*6@:Z-Ρw,+pShːN[z"7 @5$|!|{;feb$a;P+NQKc(<5xI“ ×7N$nBGՑN[] QmNeRh/kKQwmhmeeFGTv=)*4ƛ'ƲYYܡ}HN0Ay8=2svV\-$t xji^\HH0٭p% ҚhϖpWw)/,*&LԺ1[Wo1wғȰӤEG(!hZ?i5% \aZCDjgx}K'?2ex]P5xuE 02v#o@%-tH(DyTYRff y>e84-[AR:wF" {Х2NMgiY8s+6jگbNYvL%W$RjGc<-~~U%80 H@ӱb,16: YjҶH ls\Ab~슈3ó!GG]מݍƛn d;m֤u(>S;UG' (!#j\vqxO9-1XdʪEh:I D"1КiYsSR! PU\*ŕ/H,bY!2VSHa TD%mjKxJĹb1w]Wk{rU{;~=iaYߡ4h G V#ab}&@=3mXO\~|Hd$BUOrJײ)F6{q[ ?ZؖŚ\8\*O` =+#X-'94yiӿڣTەڭ#e F?LW=f(?(`n?)s]=]NgW|?#Qې9.Wtcf SwHJd]4~HUҪ kZ"a!}G'Sަw}@CRgSr>b(JrF˜4#L"r %x51 1?XV:Eu 1N*_ r'WLe`*YXdVFjSztvA'+n(tNcM 1 sY'w!MBnTu&S1ҪĞNjFq#jTkdO#ZTh}BHГko:G@FRy=j>q6}Ӓ=4^ƓM&Ft /:t*@Im5-kHjp9dg#+Ӝ秥/kP-+]:KAIq7_UfZߛU,0UG˄\s -Kmb@9mY;[x>f*:40۸'.02C"vr*=Q: Q!Q{V%]jvp`YWW$<-Gof;ɮQQW莾[օ9cOPz]άϙ=6N CH.5y$qR&>vrmei絒Yگy4Co9Y&` e mLuyr2 J9;۠ޢɨCs##yq&e,qVl.xs 9 V_- #?6z+C/'K#jdY*ijʟ*pXg(<^o-2;p*F|Ц9Z4-6#>H\]0>R{?Z[uQ3Vj8#riZ:kpǰ=SA6BWAgMk˹n$#UŽܟT5cFF+jZ fH|Q`#=i'$UvUA$%8$gb]d7WkgmI)Xz25ֺ,HYwIemx޷thQD:Np Unzշbfؓn$$Twiq$ Q9BnWԩ/%o>c #Bѷ˝tB4u4UkX#ηflZJ"$pבeֹ{4Eb ㊭;%΢6]Gzlᵳ3U6MQu4WKy)tXgixyX5ڵ# .k!$W/j彗R GbXP QO5r<c ㏥cY9<2Ʀ nCyaH qz3y:RHZ=dON]$Q 稫5Ɍ9v$9* fFUU9zY¹=&KieEiܗ^ֻ #u]XR ve;[Zg@窞j8Az! 幭Sb[OW.tlu5T4"1隧1_"DZV G+;ěPę>/os?&8&4V&'>גù{#efws_DtZkY^et=i3~sw>գey[ߴ-TqûJ4ֿdڠ_E/I8&ϥE2]FY3f9e֙qXjUuHrȸȬ{ѷ$ͻ:Y49+$UF; Am;ڷ?ud **S+Sln4w8[uP+=zU/<<\Ni!>[Sq< cc([5H3d!/b],papk:[?2Bhq*u,ܗ*r7t2p„= U#ԷжGS_rHm"=s?罼Xm9KKuD4嘻˺Qz7:&Rm c Ӆ97rtZu'`$@xn3#;Ke%?38S`W*SZ ޹-rb2vb{MNggaKLj흜rL*npTTw-+z-ŕ"Ui|ǿZ2jBzOjñ;J_W7GОWԣ5»2z⫭w|VUA~Il zt>֛dNdҒx۹W$sŴFM܍GA]*<=v]i $>Zd NíCnSX:``ӌM#lF~aQJ1H犂b7R؈ne5_Y~$8 >`!A-xA3Ym@DSMl_|׆gHO j/͸.[$Oi[H@ع=>Zns8$3JI3rGL$m}:z1_ݱ"vcpEmZI^"[?*ATŬ06Fy0W*~i:UQ]EK뺕Roq(eya ^Cm|S=iE Op 7;FII `8и pI@15sElL-?# 8wLT";B?0c{ķ |lf'ed҅ ϷJzq֭ƪ>f,r0_ QF- y,2Ut!nGGKgoZV?⮬lm31"swщrI**)2j7 aH-d^k{ɱB<4?y4 4@y-xLK$F#\Q`H|d_ c8BVzSwqN:H2lbkI !VsnǑX-X=eԮ%Btq7IwA=s:䳃13d_>f$*AzRud&ږ{pBX-H>XqqRhMs.-n+-H淺@R9#Swj6%4ڠ4$ qD3 AZIG9lLD؍!s%q#Onvɖř7b1&e68SdlUQVu w W35wl2N) <+Bq= w]\zCuwPaFa{~٤:|0kHtHKv@2hMRD:`vToކ8$3"ɝڬDF8Ui n8WMV& q{ѣ%JB/l K.8&D7 o y v tV~^/$vcρ* g&<3?_j[?ԃt*S]tz5X]ui@(dJ{x2O3/x1MY¼(t'<8⛙%ΠĨ@5Hwh!+2^Sq6 qK-Vks]Rp=0?hYiQaobpk!I qYw[.}(=E&Q8ţD @8G;Hw—8fi'dV O^.I8=+YKŴAed,VKRceeP~!9&41EE67%pMSƆBp+|  8޼A Z^Dhh=3]wxVN+ S8̌\ EH "HYGH>F- \%֥{y2Fq_Ǜϔveݞ$pé>AvbNp -{@[sU-<*g^Aaq+fiܒzgoi&Iv[G[Y+:)sxm7,yPDVբ|Ii%>N>s,PXu`x#ָYZ_T$9{*˲1.\goұ>Ƒ]dzַ?T;VNkUGP}GysJ;3Y$赫bXRsF0(tv13}S).E p% iC$^CԞ$[N]OMXj:ZBv=Ҝ#JO 71{gֲK9ȧFAQ2ǮIĂ1R,pç(QR=^pjp8?ھ_p3 }>Ֆ5ﳘ]:k1bNF[j#ND Wctյ}F0<G^iJQRn74Dj:?ըڧZ<12>\}=*p4qNIYX/C_et:`(9|Bu GjZ;"]X~Z\3Fe_4a;4yȆfaԪrjE?jͭc##֪M{u&L1ݚH94zđ"j#T '=1FC;@$Tw00^9+VO'!ܤpO=4o8K2]Da99-y%M\zPs0gsЇs;U>m-cŻqс>/Lc3 l־ZATEFfmccn W w>ըܮ#$m/#p}j,yn# k `8'QvW#Zr O{*=jšڭɌRK|78 &QBpE jw x-+flw}w$v>|`0qڤ3>JM&?MC2] G8U>&`Ӳ-p{ZӴ;8o@`;ڳoa#TL+6zU.3'ZZVw-M, rB(=B| @C?]̖X#kej20qXckZFs 4?[O&HRU#8=My'U]ÌyˏZ0' E<ΠUFIjEl VLf:Tls{UQ׎i6HdGLg]C)rS3֐ 6{V=ޯ lIp~s[P7[ʏs#~yw(x cТ31˻rXeQ9 bH iq'$#eOpHkN7wd+pN{ԩ)=$?#UyFpI zzؗQ . G"$q zjdL`>q.r2qRmIb/48L 0qS :M=L9$GOJNHdt~H{dbzgSPAoJRI4#(e>R,q֐dtRP9Sri$}1=%'zn\g"sN1x=? |uCy/~ZE%(^(4tFMqL ܐ[5Z/Zuy/-(ߝXө)1/8%4 ghu<1k"[hUI,`0+-{˱1~^p2ÍD~EsiʭSM\ \7O&"SV qt3TBGJ 4*O`͖_5o#.FNFzU4I]I8r/"6;IR *S̝wBPπ: xv'p>q8ajH<70O2h*l$Dg5v ZmAc\/w%Փ:c\ ¹jDdki5q9;"g@B7ɟA!B' ,#\T=[Gyθk׸MwN=׆5яjMJڟf4ҚH<uF9Rv<0c3'!s/ үélPNrO@Й8dJ~ei<ď>{sL$CI( 1=L@#4L rqK rI❍acPI'9qߵ(9bh (YrN>qJ7zz҃xr(~{!\O}wKH:s@W!uvSŠXD;5Oު_CaM3 ![\cT¢Q 1c[0"VmjdB7aG.ƧQ-N:1xT?mQ+~U <݇Re3~1[L5V2Z]$Z{wEpwحww');LTWz*\L|@[q3J=Cm9K1RG\K}խRȪ^JGYm p`~<ƶڻS*TG֬,ŋf[$,OxUfwdb9R YOE&NWizf]=})Ȼ y歵tj1<ՠ;FrA^n)P>ES8Bÿy3)HZ98z1h]J?*E-'zZ RR cق0+`渟X[b9"WE^HO յir7`  pW;_kne##nknCuy-gI8e9{'2"}Abec1Uy@.{{)ws=Id%8s3]Mpdr~wZIbDXdoU8yglALdLv4Ā7 sF2zw3Ji8iph mペLsO' iQ# lh8bx^zRLP[w*M(9^0@izSAN֚`v>~J?|)bW LfVB9ENJ2-$H۠5 '̣5֠WBGkTZ9[!' G SD%k09]?iMYJZH2eO*^1jz,+!t8#Ƈ# uf)80sj .1n)ړPg+AJl ln`xɤ61ZvC\HO_T.hwfIWkΥ洷83k6Is3HY~d'dfPswde0'̹/'4F~8#ŏˎ(IV"ˎsSnh<8ZLIA#ٶy4gXi'!OE#[p }7ڄ .Fؒ~䭌qDٴQb ^ttQZ\i1a#ZalrrAңs=́.3ġ\x|juPx*SQaܱxiH8Zvr%&7#9uNO4# Pˌr@@qHA?0ڜ =iA,5s1J6wa3i0=)6)Ҩxh)$cJF0 csN}fҸA(9*luv R~"'|IoX YwI9>,_S4Ϸ“v{)SXM#gCF08#IӮqb%Nr89n1ސ #iOJh':0ZU'/iP -@@l{7 J3CךP~\P:d5A OƐXc4ӽ&}i`1LC$R9?xdJ0x&A9>)Rqߥ*=)ӹP+5W2bp=5}^#Ƽ9xZot5'Tnx4+-.tw?U(5e[:u%J[+{+$JGҥAt<[Swm5izųb"ns]?a62UK "k@P`7JҺ`zQ /JZbFD3`9ǦWEZLk byy8BX4O#iǵ,7+,zƝj8P{Rg[p;bc6ITjf8w1Xg #^.% Ӹbz"FH };@Ҙ[-J2"bV}890slS":nj.YG= ^NqҐR:1Ҫ)uF-'MB7cRcG=DI1[e1ԒHK1$&$F=MFqi M''9,F4`}iFJ}nnM7njFnFZEQ94+ ]w8n)Ԓ?*:0HyPqҁ^!'`RlgUw`=/V'4X+!{}iFMYJ=GlVyv q\G#uG _֌q@4a@jMzk>%7MzmoA/!lqQ&3S8`IҰ=9AE 9 P=s\.zR8Ny@ !9S88N_}+'RF1H4\H4O9?0&' 1܏Jqҫ N\^jIW'Ubq};p-qDۉ#5彪,Ublf}R`_ wwZjOCX14"!rx]cJ˅m!'o몁6Y,~-ҧcҜґNFPIa2rz~Nqڐ8wsJ]4&3 RmcӓI$)w1ӊ'z8NMqQ>1SYNx:ӸX秥CRlg⃕#㘃ӷKXzfD׵<9=As N?zC=cJn}k[|xj.?uգΫRih3 (9^s#?lWOLd;=f~4q9#POr(i̿9@XoL8\;<SEp4CKқ|qL,9<P?ZL2X*L u1NiňP@y.$Jxxs4v~i3hjzUpz14Gj2XtS=h;qJTҗMn<8tǵP Vd*`rkAmJ0  iFAIV^A&pRGJ:g1VA2kѼQ[}KQ]\L8ʲ9A_-45K_^wdp(l]?ݤ[]@+)'Z 7n 'J.ڀCgspjqv\P 5sq8M<3ZG(ϵ #qhr#=R(1$95N0w ֙R3ӊL8L9|uMb.:baִv4FJAg4*F{u]L)żyՠdC/.u02-cG|~fL*i9( C)/@_w<}S{x8NZ GNip1Qq8|wwe&9jA}rABq=ݸdnIi(#6rꠚq?Zp}pq}_|,4i@c'&7\j>H$rqJ$ .'gK!9GX1a-6{ K 8~w$“NNfu1cm;x܎+oW{Xp^>\V7M&+sRHӒ܁|kmnuR@ 4WBݎ$) gz` }ۗ',sLnHn\m}>l ?^Ekc 5O|\,Z/r¢p&F <(irjJHhPsL ۶*Rr܊bRt穧8<}qH`2G<=hp;S[Ԉ&KGxc¶#]{k B5bSaKE-R 1{qkӈ91?s#RڇqN)SP$g)  Z{T@g$[L&:ӷ)wc< t0^:zsK ;3hR= =~tÎ}a zN_Jy9p:t /y ;d|SF_; })1xޔHS HN6pF7 ?miU}>& ☄U'48봌7;s@{ԤNR9@?5FOzvF8ȦF:qh9Ht)I(l qKps"rNAPۚ`n4c fQ,2:p_(Kʹ'?\G#Zv CTMHG]Q I[;>ɣ( H+"XװW"-C|M;;tZW]܏Z^WfVD :9{FÇ5\M#d1P;~TM':JsIsAN㰀ґg!$=za\sEa9c}TQ֚6\$dH9rM$g@9✽ANrT".|b{{?j?t+lU#ŢKARs@ 80"3^My#v2GHW-7q)x>#`3*60AyN@ii#$SD oASFn}*=]zޝ⽋#JiLZbI>¥O~.n;杀zuIz}@s4~l'9J?F듎riB?Z{#'N=i f)󎜚h:9wq$s`y*\gMqE28cE;o9)S޵HGp:NFzS?maLV܂|O#8a!m$s)$ h@&0 4 lcw\E!F[MdmG.Xw!>i0@] s4 PۛqN<Mݸ u_zap=b#,&GZb8$yG~)F2:tH֜ 8ws֝x'RZnI+r}i@9 N`p5A`R0H$JKicqG3A'\cv|[ WT/ W8g1zQIKAяz@ih"*c"sm0FX'M"(YL>sH WQKX!xEb omlV_ 1q޴mlbKYd9&#(-9}3RWi O5wY֛J%3ԾR )WY1Y^@͟)G`}h9w(=\Lohs޹@Tyϳ( S*|Oh~OOI&qP.=so-2TM+ خ>')<_8h)=F9@y|647Q^RQ{Y<_\@FgV s3J7h=n ؏ 08SGʹ)v :dP}2/H=un~^R`<@{wt3[r)6PG¼A{-T M%}I@<=?:CZ݃VH#!$dRǘ1iN|qMm)k?砯] =hy>mPX)u1h?{^r($x/]!sg@~kضAAҟ ANl"{oZ]RC̻>(bG5u'oN1F9.Ǐ7pplf|?̈́^TF)r Ի2tQrEh ?d=+_,zSACjK.7?ӣ_rה5X=E.ri<+*e~7OC]qtR1QʃO-ݯf5n{|%LT?*9P}gO|=i>&G[붽5G٢I|ʅ#~.AcTy2;gORf"* ~=x8v=kie CiC t;bBj"UGg3ww 1KE QhGUuZHmm(y }dEQq<²+# ihDZ5ɥukffP1T#.D᷺Kr#͓8\7#y%t"~QSXFLB"A8$jtou"a> N([\m_AO,W,.4$? `b޲уZd&+i#dQ}94 $/l%0[-٪WN[m;[,N*?Vl88,1#iZl֨Z ΩCb^;*5ai7 z[vJݚkWA(?7\0 *mO.uk\Hb 粓O{ձ1}S}"9+sUeƛci5dFL+${4:Iʴ$I?GA]f`b,YR^q&1S*큖ooƬ$SE[Y-l DԮtMJD0(nEޯzVFhJ' sԿދ61)+2} PӒksk**>8b]jkz^g$ 3ʋ Z{VlO-^_-^PTH(?IO,>u4,ǟҀ.xzD쩖LW'LSWSS!cR3ví]k[mݠ\/NeiWV#P exZ]v_ _$$A1S@t7ѭ`Ω8Iגk&K;}3E2foUSlWK:SY @'|U+j1d1qu7<{?:vc}j#Hng3$W M6%ψoe `cN>>uenn>4("pԣTfo-Hmێ=z4ھym4yQg]}UڭyyV^O=hKm^8cx)P >F<`>a$أ0^'..u @m6[puݑNNSYZv]mdw _ʭIq`LH¹;kp);Lq>ohKIctwRIOc*Ě൏0.en!}AD~Y*k$zf˿n兢k,r@ⳣRk[$[XO]g5Wh-cX.7 "mp!XQrNcɮ ImKZԯe$Ɋ23dsuֱ^5w)$t\qx)4-,lXܒN00OE憉{6D5A6f MBl&iQ@R:.c>{YB[s?O4xTV,18UX.j y٥V+ǜ~_ΗO[[u~T<7 52O+':~ d ˫Puv*9<{ʋΊMf$y >ǔ m^ 䳑\|GSl>o5PH f>~$?g[B@╂Avڏ-ى8e*Aޮ\Kvygxo(7w=( !&(Ը--'Z7 7PFM-.)qIg^b3ijwzZb(iyԢ J(4gZ(\@ (h.8KE1hE! (? nFu%0hh:PH$,zuV5Uڠ; }n6wj7hh}&(!߭?RvPҧ5%mmiߥl*ONi6TjJ(eIJa)SEFSJ6f(// TzLQp3l&Y`tхAj(V8*(@OF(o< b"܁rx-P~X  ASsIbT*yciF^:$F^ ]*QF:p ހI(08b1J:Ը084IFEnSj1uFE;9сR硣h(hK@%>4chQE$$If!vh5t55 5A#vt#v#v #vA:V l40+++,5t55 5Af4$$If!vh5t5555A#vt#v#v#v#vA:V l40+++,5t5555Af4$$If!vh5t5555A#vt#v#v#v#vA:V l40,5t5555A/ f4$$If!vh5t5555A#vt#v#v#v#vA:V l40,5t5555A/ f4$$If!vh5t5555A#vt#v#v#v#vA:V l40,5t5555Af4$$If!vh5t5555A#vt#v#v#v#vA:V l40,5t5555Af4$$If!vh5t5555A#vt#v#v#v#vA:V l40++,5t5555Af4$$If!vh5t5555A#vt#v#v#v#vA:V l40++,5t5555Af4$$If!vh5t5555A#vt#v#v#v#vA:V l4"0,5t5555A/ f4$$Ifl!vh5 5n5 5F#v #vn#v #vF:V l40+++,5 5n5 5Falf4$$Ifl!vh5 5n555F#v #vn#v#v#vF:V l40+++,5 5n555Falf4$$Ifl!vh5 5n555F#v #vn#v#v#vF:V l40+++,5 5n555Falf4$$Ifl!vh5 5n555F#v #vn#v#v#vF:V l40+++,5 5n555Falf4$$Ifl!vh5 5n555F#v #vn#v#v#vF:V l40+++,5 5n555Falf4$$Ifl!vh5 5n555F#v #vn#v#v#vF:V l40,5 5n555Falf4$$Ifl!vh5 5n555F#v #vn#v#v#vF:V l4A0,5 5n555Falf4$$Ifl!vh5 5n5 5F#v #vn#v #vF:V l40+++,5 5n5 5Falf4$$Ifl!vh5 5n555F#v #vn#v#v#vF:V l40+++,5 5n555Falf4$$Ifl!vh5 5n555F#v #vn#v#v#vF:V l40++++,5 5n555Falf4$$Ifl!vh5 5n555F#v #vn#v#v#vF:V l40++++,5 5n555Falf4$$Ifl!vh5 5n555F#v #vn#v#v#vF:V l40++++,5 5n555Falf4$$Ifl!vh5 5n555F#v #vn#v#v#vF:V l40,5 5n555Falf4$$Ifl!vh5 5n555F#v #vn#v#v#vF:V l40++,5 5n555Falf4$$Ifl!vh5 5n555F#v #vn#v#v#vF:V l4e0++,5 5n555Falf4$$Ifl!vh5 5n555F#v #vn#v#v#vF:V l40++,5 5n555Falf4DdHD  3 @@"?$$If{!vh5$5j 5 #v$#vj #v :V l)0,5$5j 5 a{$$If{!vh5$5j 5 #v$#vj #v :V l4S0,5$5j 5 a{f4$$If{!vh5$5j 5 #v$#vj #v :V l40,5$5j 5 a{f4$$If{!vh5$5j 5 #v$#vj #v :V l:0,5$5j 5 a{$$If{!vh5$5j 5 #v$#vj #v :V l40,5$5j 5 a{f4$$If{!vh5$5j 5 #v$#vj #v :V l40,5$5j 5 a{f4$$If{!vh5$5j 5 #v$#vj #v :V l0,5$5j 5 a{$$If{!vh5$5j 5 #v$#vj #v :V l0,5$5j 5 a{$$If{!vh5$5j 5 #v$#vj #v :V lJ0,5$5j 5 a{$$If{!vh5$5j 5 #v$#vj #v :V lV0,5$5j 5 a{$$If{!vh5$5j 5 #v$#vj #v :V lF0,5$5j 5 a{$$Ifl!vh5 5n5 5J#v #vn#v #vJ:V l40+++,5 5n5 5Jalf4$$Ifl!vh5 5n555J#v #vn#v#v#vJ:V l40+++,5 5n555Jalf4$$Ifl!vh5 5n555J#v #vn#v#v#vJ:V l40+,5 5n555Jalf4$$Ifl!vh5 5n5 5J#v #vn#v #vJ:V l40+,5 5n5 5Jalf4$$Ifl!vh5 5n555J#v #vn#v#v#vJ:V l40++++,5 5n555Jalf4$$Ifl!vh5 5n555J#v #vn#v#v#vJ:V l40++++,5 5n555Jalf4$$Ifl!vh5 5n555J#v #vn#v#v#vJ:V l40+,5 5n555Jalf4$$Ifl!vh5 5n555J#v #vn#v#v#vJ:V l4_0++++,5 5n555Jalf4$$Ifl!vh5 5n555J#v #vn#v#v#vJ:V l4_0++++,5 5n555Jalf4$$Ifl!vh5 5n555J#v #vn#v#v#vJ:V l4_0++++,5 5n555Jalf4$$Ifl!vh5 5n555J#v #vn#v#v#vJ:V l40+,5 5n555Jalf4$$Ifl!vh5 5n555J#v #vn#v#v#vJ:V l40+,5 5n555Jalf4$$Ifl!vh5 5n5 5J#v #vn#v #vJ:V l410,5 5n5 5Jalf4$$Ifl!vh5 5n5#v #vn#v:V l410+,5 5n5alf4$$Ifl!vh5 5n5#v #vn#v:V l410+,5 5n5alf4$$Ifl!vh5 5n555J#v #vn#v#v#vJ:V l460,5 5n555Jalf4$$Ifl!vh5 5n5 5J#v #vn#v #vJ:V l4/0,5 5n5 5Jalf4$$Ifl!vh5 5n555J#v #vn#v#v#vJ:V l4B0,5 5n555Jalf4$$Ifl!vh5 5n555J#v #vn#v#v#vJ:V l40++++,5 5n555Jalf4$$Ifl!vh5 5n555J#v #vn#v#v#vJ:V l40++++,5 5n555Jalf4$$Ifl!vh5 5n555J#v #vn#v#v#vJ:V l40++++,5 5n555Jalf4$$Ifl!vh5 5n555J#v #vn#v#v#vJ:V l40++++,5 5n555Jalf4$$If!vh5 5 5 #v #v #v :V l t0"6,,5 5 5 $$If!vh5 5 5 #v #v #v :V l t0"65 5 5 $$If!vh5 5 5 #v #v #v :V l t0"65 5 5 $$If!vh5 5 5 #v #v #v :V l t0"65 5 5 $$If!vh5 5 5 #v #v :V l t065 5 $$If!vh5 5 5 #v #v :V l t065 5 $$If!vh5 5 5 #v #v :V l t065 5 $$If!vh5 5 5 #v #v :V l t065 5 $$If!vh5 5 5 #v #v :V l t065 5 $$If!vh5 5 5 #v #v :V l t065 5 $$If!vh5 5 5 #v #v :V l t065 5 $$If!vh5 5 5 #v #v :V l t065 5 DdD  3 @@"?y$$If!vh5P!#vP!:V l t065P!$$If!vh55#v:V l t065}$$If!vh55#v:V l t065}$$If!vh55#v:V l t065}$$If!vh55#v:V l t065}$$If!vh55#v:V l t065}$$If!vh55#v:V l t065$$Ifl!vh5 5n5 5X#v #vn#v #vX:V l40+++,5 5n5 5Xalf4$$Ifl!vh5 5n555X#v #vn#v#v#vX:V l40+++,5 5n555Xalf4$$Ifl!vh5 5n555X#v #vn#v#v#vX:V l40++++,5 5n555Xalf4$$Ifl!vh5 5n555X#v #vn#v#v#vX:V l40++++,5 5n555Xalf4$$Ifl!vh5 5n555X#v #vn#v#v#vX:V l40++++,5 5n555Xalf4$$Ifl!vh5 5n555X#v #vn#v#v#vX:V l4:0,5 5n555Xalf4$$Ifl!vh5 5n555X#v #vn#v#v#vX:V l40++++,5 5n555Xalf4$$Ifl!vh5 5n555X#v #vn#v#v#vX:V l40++++,5 5n555Xalf4$$Ifl!vh5 5n555X#v #vn#v#v#vX:V l40++++,5 5n555Xalf4$$Ifl!vh5 5n555X#v #vn#v#v#vX:V l4L0++++,5 5n555Xalf4$$Ifl!vh5 5n5 5X#v #vn#v #vX:V l40++,5 5n5 5Xalf4$$Ifl!vh5 5n5 5X#v #vn#v #vX:V l40++,5 5n5 5Xalf4$$Ifl!vh5 5n555X#v #vn#v#v#vX:V l40++,5 5n555Xalf4$$Ifl!vh5 5n5 5X#v #vn#v #vX:V l4D0++,5 5n5 5Xalf4$$Ifl!vh5 5n555X#v #vn#v#v#vX:V l4:0,5 5n555Xalf4$$Ifl!vh5 5n555X#v #vn#v#v#vX:V l4*0,5 5n555Xalf4$$Ifl!vh5 5n555X#v #vn#v#v#vX:V l4$0,5 5n555Xalf4$$Ifl!vh5 5n5 5X#v #vn#v #vX:V l40+,5 5n5 5Xalf4$$Ifl!vh5 5n5 5X#v #vn#v #vX:V l40+,5 5n5 5Xalf4$$Ifl!vh5 5n5 5X#v #vn#v #vX:V l40+,5 5n5 5Xalf4$$Ifl!vh5 5n5 5X#v #vn#v #vX:V l4&0,5 5n5 5Xalf4$$Ifl!vh5 5n555X#v #vn#v#v#vX:V l4<0,5 5n555Xalf4$$Ifl!vh5 5n5 5\#v #vn#v #v\:V l40+++,5 5n5 5Xalf4$$Ifl!vh5 5n555\#v #vn#v#v#v\:V l40+++,5 5n555\alf4$$Ifl!vh5 5n5 5\#v #vn#v #v\:V l410,5 5n5 5Xalf4$$Ifl!vh5 5n5 5\#v #vn#v #v\:V l4F0,5 5n5 5Xalf4$$Ifl!vh5 5n555\#v #vn#v#v#v\:V l40,5 5n555Xalf4$$Ifl!vh5 5n555\#v #vn#v#v#v\:V l40,5 5n555Xalf4$$Ifl!vh5 5n555\#v #vn#v#v#v\:V l40,5 5n555Xalf4$$Ifl!vh5 5n5 5\#v #vn#v #v\:V l4-0,5 5n5 5Xalf4$$Ifl!vh5 5n555\#v #vn#v#v#v\:V l4a0++,5 5n555Xalf4$$Ifl!vh5 5n555\#v #vn#v#v#v\:V l4Z0++,,5 5n555Xalf4$$Ifl!vh5 5n555\#v #vn#v#v#v\:V l40,5 5n555\alf4$$Ifl!vh5h#vh:V l4X0,5half4$$Ifl!vh55555555#v#v#v#v#v:V l40,55555alf4$$Ifl!vh55555555#v#v#v#v#v:V l4J0,55555alf4$$Ifl!vh55555555#v#v#v#v#v:V l40,55555alf4$$Ifl!vh5 5n5 5F#v #vn#v #vF:V l40+++,5 5n5 5Falf4$$Ifl!vh5 5n555F#v #vn#v#v#vF:V l40+++,5 5n555Falf4$$Ifl!vh5 5n555F#v #vn#v#v#vF:V l4B0,5 5n555Falf4$$Ifl!vh5 5n555F#v #vn#v#v#vF:V l40+,5 5n555Falf4$$Ifl!vh5 5n5 5F#v #vn#v #vF:V l40+,5 5n5 5Falf4$$Ifl!vh5 5n555F#v #vn#v#v#vF:V l40++++,5 5n555Falf4$$Ifl!vh5 5n555F#v #vn#v#v#vF:V l40++++,5 5n555Falf4$$Ifl!vh5 5n555F#v #vn#v#v#vF:V l40++++,5 5n555F/ alf4$$Ifl!vh5 5n555F#v #vn#v#v#vF:V l40++++,5 5n555F/ alf4$$Ifl!vh5 5n555F#v #vn#v#v#vF:V l40++++,5 5n555F/ alf4$$Ifl!vh5 5n555F#v #vn#v#v#vF:V l4D0,5 5n555F/ alf4$$Ifl!vh5 5n5 5F#v #vn#v #vF:V l4]0,5 5n5 5F/ alf4$$Ifl!vh5 5n555F#v #vn#v#v#vF:V l40++++,5 5n555Falf4$$Ifl!vh5 5n555F#v #vn#v#v#vF:V l40++++,5 5n555Falf4$$Ifl!vh5 5n555F#v #vn#v#v#vF:V l40++++,5 5n555Falf4$$Ifl!vh5 5n555F#v #vn#v#v#vF:V l40++++,5 5n555Falf4$$Ifl!vh5 5n555F#v #vn#v#v#vF:V l40++++,5 5n555Falf4$$Ifl!vh5 5n555F#v #vn#v#v#vF:V l40++++,5 5n555Falf4$$Ifl!vh5 5n555F#v #vn#v#v#vF:V l40,5 5n555Falf4$$Ifl!vh555 5P#v#v#v #vP:V l40+++,555 5Palf4$$Ifl!vh555555P#v#v#v5#v#vP:V l40+++,555555Palf4$$Ifl!vh555 5P#v#v#v #vP:V l40+,555 5Palf4$$Ifl!vh555 5P#v#v#v #vP:V l4+0+,555 5Palf4$$Ifl!vh555 5P#v#v#v #vP:V l40+,555 5Palf4$$Ifl!vh555555P#v#v#v5#v#vP:V l4}0++++,555555Palf4$$Ifl!vh555555P#v#v#v5#v#vP:V l4}0++++,555555Palf4$$Ifl!vh555555P#v#v#v5#v#vP:V l4}0++++,555555Palf4$$Ifl!vh555555P#v#v#v5#v#vP:V l4#0,555555Palf4$$Ifl!vh555 5P#v#v#v #vP:V l40+++,555 5Palf4$$Ifl!vh555555P#v#v#v5#v#vP:V l40+++,555555Palf4$$Ifl!vh555555P#v#v#v5#v#vP:V l4\0+,555555Palf4$$Ifl!vh555555P#v#v#v5#v#vP:V l40+,555555Palf4$$Ifl!vh555555P#v#v#v5#v#vP:V l4P0,555555Palf4$$If!vh5R5R5S5S#vR#vS:V l065R5S$$If!vh5R5R5S5S#vR#vS:V l065R5S$$If!vh5R5R5S5S#vR#vS:V l065R5S$$If!vh5R5R5S5S#vR#vS:V l065R5S$$If!vh5R5R5S5S#vR#vS:V l065R5S$$If!vh5R5R5S5S#vR#vS:V l065R5S$$If!vh5R5R5S5S#vR#vS:V l065R5S}$$If!vh55#v:V l t065}$$If!vh55#v:V l t065}$$If!vh55#v:V l t065}$$If!vh55#v:V l t065}$$If!vh55#v:V l t065}$$If!vh55#v:V l t065}$$If!vh55#v:V l t065}$$If!vh55#v:V l t065}$$If!vh55#v:V l t065}$$If!vh55#v:V l t065!$$Ifl!vh5S5n5 555355N#vS#vn#v #v#v#v3#v#vN:V l40      ,,5S5n5 555355Nalf4%$$Ifl!v h5S5n5 555355n5 #vS#vn#v #v#v#v3#v#vn#v :V lJ0      5S5n5 555355n5 alkd9$$Ifl      J S}&,H1(5Sn 3n0      $$$$44 lal%$$Ifl!v h5S5n5 555355n5 #vS#vn#v #v#v#v3#v#vn#v :V lJ0      5S5n5 555355n5 alkd<$$Ifl      J S}&,H1(5Sn 3n0      $$$$44 lal%$$Ifl!v h5S5n5 555355n5 #vS#vn#v #v#v#v3#v#vn#v :V lJ0      5S5n5 555355n5 alkd?$$Ifl      J S}&,H1(5Sn 3n0      $$$$44 lal$$Ifl!vh555555555 5 5 5 5 5 55555555555#v#v#v#v#v#v#v#v#v #v #v #v #v #v #v#v#v#v#v#v#v#v#v#v#v:V l0      555555555 5 5 5 5 5 55555555555alRkdB$$Ifl      * e>xQ) "$d&<(*+-/w1O3(50      dddd44 lal$$Ifl!vh555555555 5 5 5 5 5 55555555555#v#v#v#v#v#v#v#v#v #v #v #v #v #v #v#v#v#v#v#v#v#v#v#v#v:V l0      555555555 5 5 5 5 5 55555555555alRkdI$$Ifl      * e>xQ) "$d&<(*+-/w1O3(50      dddd44 lal$$Ifl!vh555555555 5 5 5 5 5 55555555555#v#v#v#v#v#v#v#v#v #v #v #v #v #v #v#v#v#v#v#v#v#v#v#v#v:V l0      555555555 5 5 5 5 5 55555555555alRkdP$$Ifl      * e>xQ) "$d&<(*+-/w1O3(50      dddd44 lal$$Ifl!vh555555555 5 5 5 5 5 55555555555#v#v#v#v#v#v#v#v#v #v #v #v #v #v #v#v#v#v#v#v#v#v#v#v#v:V l0      555555555 5 5 5 5 5 55555555555alRkdW$$Ifl      * e>xQ) "$d&<(*+-/w1O3(50      dddd44 lal$$Ifl!vh555555555 5 5 5 5 5 55555555555#v#v#v#v#v#v#v#v#v #v #v #v #v #v #v#v#v#v#v#v#v#v#v#v#v:V l0      555555555 5 5 5 5 5 55555555555alRkd^^$$Ifl      * e>xQ) "$d&<(*+-/w1O3(50      dddd44 lal$$Ifl!vh555555555 5 5 5 5 5 55555555555#v#v#v#v#v#v#v#v#v #v #v #v #v #v #v#v#v#v#v#v#v#v#v#v#v:V l0      555555555 5 5 5 5 5 55555555555alRkd9e$$Ifl      * e>xQ) "$d&<(*+-/w1O3(50      dddd44 lal$$Ifl!vh555555555 5 5 5 5 5 55555555555#v#v#v#v#v#v#v#v#v #v #v #v #v #v #v#v#v#v#v#v#v#v#v#v#v:V l0      555555555 5 5 5 5 5 55555555555alRkdl$$Ifl      * e>xQ) "$d&<(*+-/w1O3(50      dddd44 lal$$Ifl!vh555555555 5 5 5 5 5 55555555555#v#v#v#v#v#v#v#v#v #v #v #v #v #v #v#v#v#v#v#v#v#v#v#v#v:V l0      555555555 5 5 5 5 5 55555555555alRkdr$$Ifl      * e>xQ) "$d&<(*+-/w1O3(50      dddd44 lal$$Ifl!vh555555555 5 5 5 5 5 55555555555#v#v#v#v#v#v#v#v#v #v #v #v #v #v #v#v#v#v#v#v#v#v#v#v#v:V l0      555555555 5 5 5 5 5 55555555555alRkdy$$Ifl      * e>xQ) "$d&<(*+-/w1O3(50      dddd44 lal$$Ifl!vh555555555 5 5 5 5 5 55555555555#v#v#v#v#v#v#v#v#v #v #v #v #v #v #v#v#v#v#v#v#v#v#v#v#v:V l0      555555555 5 5 5 5 5 55555555555alRkd$$Ifl      * e>xQ) "$d&<(*+-/w1O3(50      dddd44 lal$$IfN!vh5T 5U 5T 5U #vT #vU #vT #vU :V l@0      5T 5U 5T 5U aN1Table¿SummaryInformation( DocumentSummaryInformation8'CompObj p#<@< NormalCJ_HmH sH tH :@:  Heading 1$@&5>*>@>  Heading 2 $@&`5>*4@4  Heading 3$@&>@>  Heading 4 $@&a$5>*B@B  Heading 5$@&`a$5>*8@8  Heading 6$@&>*>@>  Heading 7$@& 5>*CJ>@>  Heading 8$@& 5>*CJ> @>  Heading 9 $@&a$5\DA@D Default Paragraph FontVi@V  Table Normal :V 44 la (k@(No List <B@< Body Texta$ 5>*CJ 2P@2 Body Text 2@C@@ Body Text Indent`DR@"D Body Text Indent 2`h4 @24 Footer 9r .)@A. Page Number4@R4 Header 9r 6Q@b6 Body Text 360>@r0 Titlea$5>**@* TOC 2^&@& TOC 1*@* TOC 3^4@4 TOC 9^ 5>*\6U@6 Hyperlink >*B*phLS@L Body Text Indent 3 ^` a$6J@6 Subtitle 5>*\FVF FollowedHyperlink >*B* phH@H  Balloon Text!CJOJQJ^JaJ*W@!* Strong5\$-C^kBax'()+,-.$-C^kBax    8212_2[!"&!"&!"&!"&!"&!"&!"&!"&! "&! "&! "&! "&! "&!"&!"&!"&!"&!"&!"&!"&!"&!"&!"&!"&!"&!"&!"&!"&!"&!"&!"&! "&!!"&!""&!#"&!$"&!%"&!&"&!'"&!("&!)"&!*"&!+"&!,"&!-"&!."&!/"&!0"&!1"&!2"&!3"&!4"&!5"&!6"&!7"&!8"&!9"&!:"& ;"& <"& ="& >"& ?"& @"& A"& B"& C"& D"& E"& F"& G"& H"& I"& J"& K"& L"& M"& N"& O"& P"& Q"& R"& S"& T"& U"& V"& W"& X"& Y"& Z"&[ ]"s&-3<E EuPsZnain{ox~~~~HOR^ar/Y[vJw@b _V (^- .i4r8>]FJQV\`ef%ggg lZrx|4-Ο!~/Xk !w+ .26 6=E(NM  #"r ! "#d$%|&!'()*+,-./01234h567j898989:;< =>?@ABC0D-EF$GHIJKLMNAOPQRSTUVWXY=Z!.>?@kl}~23ETUEJS!mKZAz9p> l D"F"G"H"I"J"K"L"M"N"O"P"Q"R"S"T"U"V"W"X"Y"Z"["\"]"^"_"`"i"j"L$%U&V&W&X&Y&Z&[&\&]&^&_&`&a&b&c&d&e&f&g&h&i&j&k&l&m&n&o&p&q&r&s&t&u&v&&&*,,11,3-34445555556 66l8m8n8v8w899u999~<<<<<<<<<<==="='=9=A=\=]=g=v=}========?"@@"AUAAYCZC[C\C}C~CCCCCCCCCCD DDDDD$Dl?l@lAlUlZldlmltl|l}l~llllllllllllllllllmmmmm'm2m5m7m8m\m_mbmimjmymmmmmmmmmmmmmmmmnnn)n*n9n:n?nQnanlnqnsntnunvnnnnnnnnnnnnnnoohosotouovowoxoyo|o}ooo1p3pJVWmno*Jab(QYu/?DR %1PSgvw  ;<GL]nv{|<=LQ_joy~K)*+=>@AGw@t+"#12-Ohi55j5]p[U}:;Z[?@a&Zghcdn o U    b c   '(38Zbghpuv~67FKX`anqr|ABIJKLMNOPQRSTUVWXYZ[\]^_`jk~2GctxN O P Q R S T U V W X            !!%!)!*!,!/!9!?!A!D!Q!W!Y!Z!j!o!w!|!~!!!!!!!!!!!!"L$&&&&&&&&&''%'4'5'>'C'M'U'c'g'j't'~'''''''''''''''''''''(((((+(,(-(.(6(F(L(](^(_(s(t( ))+)))&*R*****,,,,]-^-... .8.9.>.M.S.T.`.{.....//%/@/p/q///////0-0b0000001I1z1111122.2`222222233.3@3\333333c4d4e4g4j4k4l4m4444444444555#5(5)5/53555A5T5_5`5o5t5}55555555555555555556 6666*65666B6C6H6m6u6666666666666666666677(7C7D7S7X7b7m7r7|777777777777777888883868@8F8I8S8Y8\8g8m8n8o8p8q8r8s8888k999@::;;;W<<<=?====>?aAbABBBBC!DYFZF[F\F]F^F_F`FzF{F4G5GGGG6HHI>I?IIIIIIIIIII5J6J7JPJQJRJ`JaJJJJJJJJJJJJJJJJJJ=KKLLLL;MMM)NNNN OO^OsPQQQQQQQQnRoRRRSFSGSTTTTgUVbWcWYY7[8[[[[[\\\\\\\\\\\\\\\\\\\]]] ] ] ] ]"]#]$]=]>]W]X]Y]]]]]]]]&^'^^^^^^^^ _ _____*_+_<_=_V_W_X_Y_______`````|aaaab$b)b2b3b4bSbTbUbVbWbbb)cCcDcEcOcPcQcRcScTcccddd#d$ddd&eTeUeVe`eaejeeetfff=gggggg"hkhhiiijVjWjljmjj&kkkkk l lllnnnn$o%ouoooppp\q]qYrZrhrrrr s!stttttvvvvvKwwxxxxxxxxxxxxxx x!x"x#x$x4x5xxxx)y*yyyyyzz$zRzlzzzz {>|?||||||}}}}}ҁӁ./ȅՅ)*GHSTw*+TБёUV/013458;<=>?@ABCDEFGHINO*MNWXt—ߗ ,-01<=./<ΟϟܟРѠ"עآNOt£ãIJs[\qNONܫEԬ0~ݲmɳ{жOѷ@vwոHI}*q!QRIlo$DOP`uz{45B GIJKL}~ !",12@DE\`ab$';JKWfu ./AFR[afgv{'VYdy*1?YZ  '.7;<EJU`deot|9DEPUaefrw'FI]lm)*8=?HQR`eoz~!#$.KP`tu"+5:EJOPTUV "&*./OT\dlt|5678FGopqrpqOP`aNO     lm  '0<[^r    ' , 6 F w x                     & + 2 7 C D N S ^ s t                     " , / = G H S X Y ^ j k l m n o p q r s t u ~    &'*+(*56K )Sy!;<{D.7Cbey"Btv} '12gn     + D T b f            !!!R!!!!!!!!!!!!!!!!!!!##2$~$$%%%&&Q(R(}(~((((((((()))=)[)))))) * **(*F*G*H*N*`*******+++w+x+++++++++++ ,",#,$,%,b,e,f,v,x,y,,,,,,,,,,,, - --5-6-7-8-e-~------------. . . . . ..5.S.g.h.......$/O/W/X/u//////00*0E0F0Y0{0000000L1~1111D2E2F2f2222222233 393i333333484E44444445T55555555555555666666666667 7N9f9p9999990::::q=====>> ? ?V??????+@z@@ABBCCCC D?D@DQDDDDDEE EWEeEEEEEEEE*x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x Ճx Ճx Ճx x x  x x x x x Ճx b0x Ճx b0x Ճx Ճx Ճx Ճx Ճx x x x Hx Hx Ճx b0x b0x Hx b0x Ճx Hx x x Hx x x x x x x Ճx Ճx Hx Ճx Hx x x Hx Hx Hx x x Hx Hx Hx Hx Ճx Ճx Hx x x Hx Ճx Hx Ճx Ճx x  x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x  v:v: v: v:v:v:tA^^d v:v:A^A^A^v:v:v:YA^A^A^YA^A^A^Y v:v:Av:Av:v:v:ޅ v:v:A^A^v:v:A^A^A^x! v:v:A^A^A^v:v:v:YA^A^A^- v:v: v:v:\ v: v:y? v:v:v:Av:Av:v:v:v:v:v:`v:v: v: v:}  v:v:Av:Av:v:v:ޅ v:v:Av:v:v:-^ v:v:Av:v:v:JO v: v:v: v: v:v:tv: v:v:tv: v:v: v:v: v:v:BT v:v:A^v:v:x x x x  v:v: v: v:v:v:tA^^d v:v: v:v:o v:v: v: v: v:v: v:v:Av:v:v:V v:v:Av:v:v:v:      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvxyz{|}~K$  v:v:Av:Av:Av:Av:v:v:v:v:v:P  v: v:v: v:v:e v: v:v:Av:Av:v:^^`v:Av:v:=  v: v:v:v:v:v:v:Av:Av:Av:Av:Av:Av:v:v:v:Uwx x x v:H@^^^^^^^^@^@^^^^^^^^(@^^^^^^^^a x x x x Mx x Mx x x x  x x x x x x x x x x x x x x x x x x x x x x x x x x x x  x x x x x x x x x x x x x x x x x x x x x x x x x x x x  x x x x x x x x x x x x  v:v: v: v:nv:nv:tA^^d v:v:Av:Av:Av:v:v:v:nv: v:v:Av:v:nv:v: v:nv:t v:v:A^A^A^v:v:nv:nv:4 A^A^ v:v:A^A^v:nv:A^A^A^A^ v:v:Av:v:nv: v:v: v:nv: v:v:A^A^v:nv:A^A^A^A^ v:v:A^A^v:nv:A^A^A^A^ v:v:Av:v:nv: px x x x x x x x x x x x x x x x x x x x x x x x x x x  x x x x x x x x x Hx Hx Hx Hx x x Hx Hx Hx x x x x x x x x x x x x x x x x x x x x x x x x x x v:v: v: v:xv:xv:t]^^dv:v: v: v:xv:v: v:xv:`v: v:xv:Av:v:]^]^v:xv:]^]^]^]^v:v:]v:v:xv:`v:v: v: v:xv:xv:t]v:v:\v:v:]v:]v:v:xv:3v:]v:v:xv:xv:v:v:v:v:]v:v:xv:xv:7x x x x x x x x x x x x x x x x x x x Hx Hx Ճx Hx Ճx Ճx b0x | x x x zv:zv:{v:{v:u:zv:zv:{v:{v:`zv:zv:{v:{v:tzv:zv:{v:{v:`zv:zv:{v:{v:tzv:zv:{v:{v:tzv:zv:{v:{v:`x x v:x x x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x v:x x Hx Hx x x Hx Hx Hx x x Hx Hx Hx x x Hx Hx x x Hx Hx Hx Hx Hx x x Hx Hx Hx Hx Hx x x Hx Hx Hx Hx Hx Ճx x x x Hx Hx Hx x x Hx Hx Hx Hx x x Hx Hx Hx Hx x x Hx Hx Hx Hx x x Hx x x Hx Hx Hx Ճx x x x x x x x x x x x x x x x x x x x x x x x x x Hx Hx Hx Hx Hx Hx Hx Ճx x x x x x x x x x x x x x Hx Hx Hx Hx x x x x x x x x x x x Hx Hx x x Hx Hx Hx Hx Hx x x x Hx Hx Hx Hx Hx x x x x x x x x x x x Hx Hx Hx Hx Hx x x x x x x Hx Hx Hx Hx Hx Ճx x x x x x x x x x x x jx ^x ^x fx F9F9F9+9+9+9+999999,9,9,9,9,9,9+9+9+9+9+9+9+9+9999l9l9l999999l9l9l9l9l999999999   !.>?@kl}~23ETUEJS!mKZAz9p> l m  a @ fniap YHD"l_>(v WF?/~a N 7!!D"F"G"H"I"J"K"L"M"N"O"P"Q"R"S"T"U"V"W"X"Y"Z"["\"]"^"_"`"i"j"L$%U&V&W&X&Y&Z&[&\&]&^&_&`&a&b&c&d&e&f&g&h&i&j&k&l&m&n&o&p&q&r&s&t&u&v&&&*,,11,3-34445555556 66l8m8n8v8w899u999~<<<<<<<<<<<<===="='=9=A=\=]=g=v=}========?"@@"AUAAYCZC[C\C}C~CCCCCCCCCCCCCD DDDDD$Dl?l@lAlUlZldlmltl|l}l~llllllllllllllllllllm m m m mmmmm'm2m5m7m8m\m]m^m_mbmemfmgmhmimjmymmmmmmmmmmmmmmmmnnnnn%n&n'n(n)n*n9n:n?nQnanlnqnsntnunvnnnnnnnnnnnnnnnoohosotouovowoxoyozo|o}ooo1p3popqrstJz7QRS›Ûěgh՞XŠLʡˡܡ./@V{Y'=$%¦Aj sҨ7-aڬ۬ܬC|̭ͭNOvگu԰հְ56;<GTVWXYZ[\]^jrz{z{|ҳ-QRn=ABv)/ջֻ,-/0>?Xghi 89:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcst:i ,KLMNbpqr|#+pqr !"#$%&'IJ23MNV/0[\LMx'~^_WX|}2STv4_\v!:UVxy!">JVWmno*Jab(QYu/?DR %1PQRSguvw  ;<GL]nv{|<=LQ_joy~K)*+=>@AGw@t+"#12-Ohi55j5]p[U}:;Z[?@a&Zghcdn o U    b c   &'(38Zbghpuv~67FKX`anopqr|ABIJKLMNOPQRSTUVWXYZ[\]^_`jk~2GctxN O P Q R S T U V W X               !!%!)!*!,!-!.!/!9!>!?!A!B!C!D!Q!V!W!Y!Z!j!o!w!|!~!!!!!!!!!!!!"L$&&&&&&&&&''''%'3'4'5'>'C'M'U'c'g'h'i'j't'|'}'~'''''''''''''''''''''''''(((((((+(,(-(.(6(F(L(](^(_(s(t( ))+)))&*R*****,,,,]-^-.... .8.9.>.M.S.T.`.{.....//%/@/p/q///////0-0b0000001I1z1111122.2`222222233.3@3\333333c4d4e4g4h4j4k4l4m4444444444445555#5(5)5/5354555A5T5_5`5o5t5}5555555555555555555555556 6 6 66666666*636465666B6C6H6m6u666666666666666666666777(7C7D7S7X7b7m7r7|7777777777777778888838485868@8D8E8F8G8H8I8S8W8X8Y8Z8[8\8g8k8l8m8n8o8p8q8r8s8888k999@::;;;W<<<=?====>?aAbABBBBC!DYFZF[F\F]F^F_F`FzF{F4G5GGGG6HHI>I?IIIIIIIIIII5J6J7JPJQJRJ`JaJJJJJJJJJJJJJJJJJJ=KKLLLL;MMM)NNNN OO^OsPQQQQQQQQnRoRRRSFSGSTTTTgUVbWcWYY7[8[[[[[\\\\\\\\\\\\\\\\\\\]]] ] ] ] ]"]#]$]=]>]W]X]Y]]]]]]]]&^'^^^^^^^^ _ _____*_+_<_=_V_W_X_Y_______`````|aaaab$b)b2b3b4bSbTbUbVbWbbb)cCcDcEcOcPcQcRcScTcccddd#d$ddd&eTeUeVe`eaejeeetfff=ggggggg"hkhhiiijVjWjljmjj&kkkkk l lllnnnn$o%ouoooppp\q]qYrZrhrrrr s!stttttvvvvvKwwxxxxxxxxxxxxxx x!x"x#x$x4x5xxxx)y*yyyyyzz$zRzlzzzz {>|?||||||}}}}}ҁӁ./ȅՅ)*GHSTw*+TБёUV/013458;<=>?@ABCDEFGHINO*MNWXt—ߗ ,-01<=./<ΟϟܟРѠ"עآNOt£ãIJs[\qNONܫEԬ0~ݲmɳ{жOѷ@vwոHI}*q!QRIlo$DOP`uz{45B GIJKL}~ !",12@DE\`ab$%&';IJKWfu ,-./AFR[afgv{'VWXYdy*1?YZ   '.7;<EJU`deot|9DEPUaefrw'FGHI]klm)*8=?HQR`eoz~!#$.KP`tu"+5:EJOPTUV "&*./OT\dlt|5678FGopqrpqOP`aNO     lm  '0<[\]^r    ' , 6 F w x                                 & + 2 7 C D N S ^ s t                               " * + , - . / = E F G H S X Y ^ j k l m n o p q r s t u ~    &'*+(*56K )Sy!;<{D.7Cbcdey"Btuv} '/012gn        + D T b f             !!!R!!!!!!!!!!!!!!!!!!!!##2$~$$%%%&&Q(R(}(~((((((((()))=)[)))))) * **(*F*G*H*N*`*******+++w+x+++++++++++ ,",#,$,%,b,e,f,v,x,y,,,,,,,,,,,, - --5-6-7-8-e-~------------. . . . . ..5.S.g.h.......$/O/W/X/u//////00*0E0F0Y0{0000000L1~1111D2E2F2f2222222233 393i333333484E44444445T55555555555555666666666 6667 7*7A7d7u7v7z8{8889N9f9p9999990::::q=====>> ? ?V??????+@z@@ABBCCCC D?D@DQDDDDDEE EWEeEEEEEEEEwOwew{wwwwwwwx xx'x0xAxRxxxxxxxAyByUy{yyyyzz#zQzzzzzzzzzzz{{{{{{{{{H{d{u{{{{{{|||} }=}>}h}}}}}(~)~?~~~~~~0f̀WÃlg/0]Us>?lڎێoplm#$+2AYhiǓȓ͔̔ghKLӘԘ-9Oqr{ՙ֙56PQDFYZ[ڛܛpqޟߟZ[٣J|}EFG˦ϦЦ*./9=>HƧǧاۧܧݧާߧBCD̨ͨN}ͩѩҩөCDEFefgh٪ڪ۪r N٬ڬ78[ҭ߭      !"#$%&',-./0123456789:;<=>?@ABCDESTUVWXYZ[\]^_`abcdefghijkl®îĮŮƮǮȮɮڮۮܮݮޮ߮     ,-./0123456789:;<=>?@ABCDEPQRSTUVWXYZ[\]^_`abcdefghiyz{|}~¯įůЯѯүޯ߯vwx&'Zklϱ  .Qnò޲"456=>?STU]bhnop{|}ɳҳӳԳ*+,39HRSTZbqrszԴմִ00000000000000000000000000000000000000000000000000000000000000000000000000000p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p00`"0`"0`"0`"00U&0U&0U&0U&0U&0U&0U&0U&0U&0U&0U&0U&0U&0U&0U&0U&0U&0U&0U&0U&0U&0U&0U&0U&0U&0U&0U&0U&0U&0U&0U&0U&00v&0v&0v&0v&0v&0v&0v&0v&0v&0040404 04 04 04 04 04 040404040400n80n80n80n80n80n80n80n80n80n80n8 0n8 0n8 0n8 0n8 0n8 0n8 0n8 0n8 0n8 0n8 0n8 0n8 0n8 0n8 0n8 0n8 0n8 0n8 0n8 0n8 0n8 0n8 0n8 0n8 000=0= 0= 0= 0= 0=0=0=0=0=0=0=0=0= 0= 0= 0=0= 0= 0= 0= 0= 0= 0= 0= 0= 0= 0= 0= 0= 0= 0=0=0=0=0= 0=0= 0= 0= 0=0= 0= 0=0=0=0=0=0=0=0=0=0=0=00E0E0E 0E 0E 0E 0E 0E0E0E0E 0E 0E 0E 0E 0E 0E 0E 0E 0E0E0E0E0E0E0E0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E0E 0E 0E0E0E0E0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E0E0E0E 0E 0E 0E 0E 0E0E 0E0E 0E 0E 0E 0E0E0E0E0E0E0E0E0E0E0E0E0E0E0E0E0E0E0E0E0E0E0E0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E0E0E0E0E0E0E0E0E0E0E0E0E0E0E0E 0E 0E 0E0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E0E 0E 0E 0E 0E0E 0E 0E 0E 0E 0E0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E0E 0E 0E 0E0E0E 0E 0E 0E 0E 0E 0E 0E0E0E0E 0E0E0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E 0E0E0E0E0E0E00}o0}o0}o0}o 0}o 0}o 0}o 0}o 0}o 0}o 0}o0}o0}o0}o0}o0}o0}o0}o0}o0}o0}o0}o0}o0}o 0}o 0}o0}o 0}o0}o 0}o 0}o 0}o 0}o 0}o 0}o 0}o 0}o 0}o 0}o0}o0}o0}o 0}o 0}o 0}o 0}o 0}o 0}o 0}o 0}o 0}o 0}o 0}o 0}o 0}o 0}o 0}o 0}o 0}o 0}o0}o0}o0}o0}o0}o 0}o 0}o 0}o 0}o 0}o 0}o 0}o 0}o 0}o0}o00${0${0${0${ 0${ 0${ 0${ 0${ 0${ 0${0${0${0${0${0${0${0${0${00~0~0~0~0~ 0~ 0~ 0~ 0~ 0~ 0~ 0~ 0~ 0~ 0 ~ 0 ~ 0 ~ 0 ~ 0 ~0~0~0~0~0~0~0~0~0~0~0~0~0~0~0~0~0~0~0~0~0~0~0~0~0~0~0~0~0~0~0~0~0~0~0~0~ 0~ 0~ 0~ 0~ 0~ 0~ 0~ 0~ 0~ 0~ 0~ 0~ 0~0~0~0~ 0~ 0~ 0~ 0~ 0~ 0~0~ 0~ 0~ 0~ 0~ 0~ 0~0~ 0~ 0~ 0~ 0~ 0~ 0~0~ 0~ 0~ 0~ 0~0~ 0~ 0~ 0~ 0~0~0~ 0~ 0~ 0~ 0~ 0~ 0~ 0~ 0~ 0~ 0~0~ 0~0~ 0~ 0~ 0~ 0~ 0~ 0~ 0~ 0~ 0~ 0~ 0~ 0~ 0~ 0~ 0~0~ 0~ 0~ 0~ 0~0~0~0~0~0~0~0~0~0~0~0~0~0~0~0~0~0~0~0~00_0_0_0_0_G 0_G 0_G 0_G 0_G 0_G 0_G 0_G 0_0_0_0_0_H 0_H 0_H 0_H 0_H 0_H 0_H 0_0_0_0_0_J 0_I 0_0_0_I 0_I 0_I 0_I 0_0_0_0_I 0_I 0_I 0_I 0_I 0 _0_0_0_0_0_0_0ě0ě0_0h0h0hK 0hK 0hK 0hK 0hK 0hK 0h0h0_0ˡ0ˡL 0ˡL 0ˡL 0ˡL 0ˡ0ˡ0ˡ0ˡ0ˡ0ˡ0ˡ0ˡM 0ˡM 0ˡM 0ˡM 0ˡM 0ˡM 0ˡ0ˡ0ˡ0ˡ0_00O 0N 0N 0N 0N 0N 0N 000P 0P 0P 0P 0000T 0T 0T 000_00Q 0Q 0Q 0Q 0Q 00000000_0ͭS 0ͭ0ͭ0ͭ0ͭ0ͭR 0ͭR 0ͭR 0ͭ0ͭ0ͭ0ͭS 0ͭS 0ͭS 0ͭ0ͭ0ͭS 0ͭQ 0ͭQ 0ͭ0ͭ0ͭ0_0ְU 0ְ0ְU 0ְ0ְU 0ְU 0ְU 0ְU 0ְU 0ְU 0ְU 0ְU 0 ְU 0 ְU 0 ְ0ְU 0 ְU 0 ְU 0ְ0ְ0ְ0ְ0ְ0_0|0|V 0|V 0|V 0|0|0_0R0RW 0RW 0RW 0R0R0_000Y 0Y 0Y 000_0ֻX 0ֻX 0ֻX 0ֻ0ֻX 0ֻ0ֻX 0ֻX 0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻX 0ֻX 0ֻ0ֻ0ֻ0ֻV 0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ0ֻ000c0c0c0c0c0c0c0c0c 0c 0c0c 0c0c 0c 0c 0c 0c 0c 0c 0c 0c 0c 0c 0c 0c 0c 0c0c 0c0c0c0c0c0c 0c 0c 0c 0c 0c 0c 0c 0c 0c 0c 0c 0c 0c 0c 0c 0c0c 0c 0c 0c 0c0c0c0c0c0c0c0c0c0c0c0c0c00'0'0'0'0'0'0'0'0'0'0'0'0'0'0'E 0'E 0'E 0'E 0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0'0000o0o0o0o0o0o0o0o0o0o0o0o0o0o0o0o0o0o0o0o0o0o0o0o! 0o! 0o! 0o! 0o0o0o 0o 0o 0o 0o0o0o0o0o0o0o0o0o 0o 0o0o 0o0o 0o 0o 0o 0o 0o 0o 0o 0o 0o 0o0o 0o 0o 0o 0o 0o0o 0o0o0o 0o 0o 0o 0o 0o 0o0o 0o 0o 0o 0o 0o 0o 0o 0o 0o0o 0o 0o0o 0o 0o0o0o 0o 0o 0o 0o 0o0o0o0o 0o 0o 0o0o0o0o0o0o0o0o0o0o000+0+0+0+0+0+0+0+0+0+0+' 0+' 0+' 0+' 0+' 0+' 0+' 0+0+0+( 0+( 0+0+0+0+) 0+) 0+) 0+0+0+0+0+0+0+* 0+* 0+* 0+* 0+* 0+* 0+0++ 0+0++ 0+0+0+0++ 0++ 0++ 0++ 0+0+0++ 0++ 0++ 0++ 0 +0+0+0+0+0+0+0+0+0+0+0+0+0+0+0+0+0+0+0+0+0+, 0+, 0+0+0+0+0+0+0+0+0+0+0+0+00000000000000000000000000000 0 00 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 00 0 0 0 0 0 0 00 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0000 0 0 0000000000000000000000000000000000000000000000000000`0`0`0`0`0`0`0`0`0`0`0`0`0`0`0` 0` 0` 0` 0` 0` 0`0`0`0`0`0`0`0`0`0`0`0`0`0` 0` 0` 0`0` 0` 0` 0` 0` 0` 0` 0` 0` 0` 0`0` 0` 0` 0` 0` 0` 0`0` 0` 0` 0` 0` 0` 0`0` 0` 0` 0` 0` 0` 0` 0` 0` 0` 0` 0` 0`0` 0` 0` 0` 000!0!0!0!0!0!0!0! 0! 0!0! 0!0! 0! 0! 0! 0! 0! 0! 0! 0! 0! 0!0! 0! 0! 0! 0! 0! 0!0! 0! 0! 0! 0! 0! 0!0! 0! 0! 0! 0!0! 0! 0!0!0!0!0!0! 0! 0! 0! 0! 0! 0! 0! 0!0! 0! 0! 0! 0! 0! 0! 0! 0! 0! 0!0! 0! 0! 0! 0!00_(0_(0_(0_(0_( 0_( 0_( 0_( 0_( 0_( 0_(0_(0_(0_(0_(0_(0_(0_(0_(0_(0_(0_(0_(0_(0_(0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_(0_(0_( 0_(0_(0_( 0_( 0_( 0_( 0_(0_(0_(0_(0_( 0_( 0_( 0_( 0_(0_(0_(0_(0_( 0_( 0_( 0_( 0_(0_( 0_( 0_( 0_( 0_(0_( 0_( 0_( 0_( 0_(0_( 0_( 0_(0_(0_(0_(0_(0_(0_(0_(0_(0_( 0_( 0_(0_( 0_(0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_(0_( 0_( 0_( 0_( 0_( 0_( 0_(0_( 0_( 0_( 0_( 0_( 0_( 0_(0_( 0_( 0_( 0_( 0_( 0_( 0_(0_( 0_( 0_( 0_( 0_( 0_( 0_(0_( 0_( 0_( 0_( 0_( 0_( 0_(0_( 0_( 0_( 0_( 0_(0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_(0_( 0_( 0_( 0_( 0_(0_(0_( 0_( 0_( 0_( 0_( 0_( 0_(0_(0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_(0_(0_(0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_( 0_(0_( 0_( 0_( 0_( 0_( 0_( 0_(0_( 0_( 0_( 0_( 0_( 0_( 0_(0_( 0_( 0_( 0_( 0_( 0_( 0_(0_( 0_( 0_( 0_( 0_(000p80p800s80080808A 08A 08A 08A 0808080808B 08B 08B 08B 0808080808080808080B0B0B0B0B0B0B0B0B0B0B080`F0`F0`F0`F0`F0`FC 0`FC 0`FC 0`FC 0`F0`F0`F0`F 0`F 0`F 0`F 0`F0`F 0`F0`F 0`F0`F 0`F 0`F0`F0`F 0`F0`F 0`F0`F 0`F 0`F0`F0`F 0`F0`F 0`F0`F 0`F 000000J0J0J0J0J0J0J0L0L0L0L0LD 0LD 0LD 0LD 0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L 0L 0L 0L 0L0L0L0L0L0L0L0L0L0L0L0L 0L0L0L0L0L0L0L0L0L0L 0L0L0L0L0L0L0L0L 0L 0L0L0L0L0L0L0L0L 0L0L0L0L0L0L0L0L 0L0L0L0L0L0L 0L 0L0J0`0`0`0`0`0`0` 0` 0` 0` 0`0`0`0`0` 0`0` 0`0`0` 0` 0`0`0`0`0`0` 0`0` 0`0` 0` 0`0` 0`0` 0`0`0` 0` 0`0` 0`0`0`0`0`0` 0`0`0`0`0` 0` 0J0g0g0g0gF 0g0g0gF 0g0g0J0Wj0Wj0Wj0Wj0Wj0J0k0k0k0J0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l0 l00$x0$x% 0$x% 0$x      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvxyz{|}~% 0$x0$x0$x& 0$x& 0$x& 0$x& 0$x0$x0$x0$x# 0$x# 0$x$ 0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x$ 0$x$ 0$x$ 0$x$ 0$x$ 0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x0$x00I0I0I0I0I0N 0N 0N 0N 0N 0N 0N 0N 0N 0N 0 N 0 N0N0N0N0N0I010101(01000(01(010/0/(010ϟ0ϟ(010Ѡ0Ѡ0Ѡ0Ѡ0Ѡ0Ѡ0Ѡ0Ѡ0Ѡ0Ѡ0Ѡ0Ѡ0Ѡ0Ѡ0Ѡ0Ѡ0Ѡ0Ѡ0Ѡ0Ѡ0Ѡ0Ѡ0Ѡ0Ѡ 0Ѡ 0Ѡ 0Ѡ0Ѡ0Ѡ0Ѡ0Ѡ0Ѡ0Ѡ0Ѡ" 0Ѡ" 0Ѡ 0Ѡ 0Ѡ 0Ѡ 0Ѡ 0Ѡ 0Ѡ 0Ѡ0Ѡ0Ѡ0Ѡ 0Ѡ 0Ѡ 0Ѡ 0Ѡ 0Ѡ 0Ѡ 0Ѡ 0Ѡ 0Ѡ0Ѡ0Ѡ 0Ѡ 0Ѡ0Ѡ0Ѡ0Ѡ0Ѡ= 0Ѡ= 0Ѡ= 0Ѡ= 0Ѡ= 0Ѡ= 0Ѡ0Ѡ= 0Ѡ> 0Ѡ> 0Ѡ> 0Ѡ0Ѡ= 0Ѡ? 0Ѡ? 0Ѡ? 0Ѡ? 0Ѡ? 0Ѡ? 0Ѡ? 0Ѡ0Ѡ0Ѡ@ 0Ѡ@ 0Ѡ@ 0Ѡ@ 0Ѡ@ 0Ѡ0Ѡ(0100(01000 0 0 0 0 0 0 0 00(010P0P(0100(01000000(010{0{(010505(0100(0100(0100000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00000000000 0 00 00 0 0 0 0 0 0 0 0 0 000 00 0 0 0 0 000 0 0 0 0 0 000 0 0 0 0 0 00 0 0 0 0 0 00 0 0 0 0 0 000 0 0 0 0 0 000 00 0 0 0 0 000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 00 00 000 0 0 00 00 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00000 0 00 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 000 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0000 0000 0 0 00 0 0 0 0 00 0 00 0 00 0 0 0 0 0 0 0 00 00000 000000 0 00 0 0000 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0000000000000000000000000000000000000000000000000000000000000000000000000000000 0 00 00 0 0 0 0 0 0 0 0 0 000 000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 000 00 00 0 0 0 00 0 0 0 0 0 00 0 0 0 0 0 00 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 00 0 0 0 0 0 00 0 0 0 0 0 00 0 0 0 0 0 00 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0000000p 0p 0p 0p 00u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u . 0u . 0u . 0u . 0u 0u 0u / 0u / 0u / 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u 0u  0u  0u 0u  0u 0u  0u  0u  0u  0u  0u  0u  0u  0u  0u  0u 0u  0u  0u  0u  0u  0u  0u  0u  0u  0u  0u  0u  0u  0u  0u  0u 0u  0u  0u  0u  0u  0u  0u 0u  0u  0u  0u  0u  0u  0u 0u  0u  0u  0u  0u  0u  0u  0u  0u  0u  0u  0u  0u 0u  0u 0u  0u  0u  0u  0u  0u  0u  0u  0u  0u  0u 0u  0u  0u  0u  0u  0u  0u  0u  0u 0u  0u  0u  0u 0u 0u  0u  0u  0u 0u  0u  0u 0000000!0!0!0!0!0!0!000!0!0! 0! 0! 0! 0! 0! 0! 0! 0!0!0!0!0! 0! 0! 0! 0! 0! 0! 0! 0! 0! 0! 0! 0! 0! 0! 0! 0! 0! 0! 0! 0! 0! 0! 0! 0! 0! 0! 0! 0! 0! 0! 0! 0! 0! 0! 0!0+0!0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+0w+ 0w+ 0w+ 0w+0w+ 0w+ 0w+ 0w+ 0w+0w+ 0w+ 0w+ 0w+ 0w+0w+ 0w+ 0w+ 0w+0w+ 0w+ 0w+ 0w+ 0w+ 0w+ 0w+0w+ 0w+ 0w+ 0w+ 0w+ 0w+ 0w+0w+ 0w+ 0w+ 0w+ 0w+ 0w+ 0w+ 0w+0w+0w+ 0w+ 0w+ 0w+ 0w+0w+ 0w+ 0w+ 0w+ 0w+ 0w+0w+ 0 w+ 0w+ 0w+ 0w+ 0w+0w+ 0 w+ 0w+ 0w+ 0w+ 0w+0w+ 0 w+ 0w+0w+0w+ 0w+ 0w+ 0w+ 0w+0w+00505050505050505050505050505050505050500 60 60 60 6< 0 6< 0 6< 0 60 60 60 60 60 0 60 0 60 0 60 0 60 0 60 0 60 0 60 0 60 0 60 0 60 0 60 60 60 60 60 60 60 60 60 60 60 60 60 62 0 62 0 62 0 62 0 60 61 0 61 0 61 0 61 0 61 0 61 0 61 0 60 60 60 64 0 64 0 60 60 63 0 63 0 63 0 63 0 63 0 60 60 60 66 0 66 0 66 0 66 0 66 0 60 60 60 65 0 65 0 65 0 65 0 65 0 65 0 60 60 65 0G 65 0G 65 0G 65 0G 65 0G 60 60 60 60 60 60 68 0 68 0 68 0 68 0 68 0 68 0 60 67 0 67 0 67 0 67 0 67 0 67 0 67 0 67 0 67 0 67 0 60 60 60 60 60 60 60 60 60 6: 0 6: 0 6: 0 60 60 69 0 69 0 69 0 69 0 60 60 60 60 60 6; 0 6; 0 6; 0 6; 0 6; 0 6; 0 6; 0 6; 0 6; 0 60 60 60 60 60 60 60 60 60 600~U00U0U0U0U0U0U0U0U0U0U0U0U0U0U0U0U0U0U0U0U0U0U0U0U0U0U0U0U0U0U0U0U0U0U0U0U0U0U0U00Y0Y0Y0Y0Y0Y0Y0Y0Y0Y0Y0Y0Y0Y0Y0Y0Y0Y0Y0Y0Y0Y- 0Y0Y- 0Y0Y- 0Y0Y- 0Y0Y- 0Y0Y- 0Y0Y0Y0Y0Y0Y0Y0Y0Y0Y0Y0Y0Y0Y00l 0l 0l 0l 0l 0l 0l 0l 0l 0l 0 l 0 l 0 l 0 l 0 l 0l 0l 0l 0l 0l 0l0l0l0l0l0l0l0l0l0l0l0l0l0l0l0l0l00s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0sZ 0sZ 0sZ 0sZ 0sZ 0sZ 0sZ 0sZ 0sZ 0sZ 0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s0s00ێ0ێ0ێ0ێX0ێ0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p0p000000000000000000000000 000000000000000000000000000000000000000000000G0G 0G 0G0G 0G 0G0G 0G 0G0G 0G 0G0G 0G 0G0G 0G 0G0G 0G 0G0G 0G 0G0G 0G 0G0G 0G 0G0G0G0G0G0G0G0G0G0G0G0G0G0G0G0G0G0G0G0G0G0G0G0G0G0G00000000000000000000000000000000000000000000000000000000000 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0000000000000000000000000000 000000 000000 000000 0 000000000000000000000000000000000000000000000000000000000000000 00000000000000000000 XXX[=[vG? !p"P##$$%&'k()Es"!:yhg/}=@lVȽ$ 3Ynj}4_efghijklmopqrstuvwyz{|}~%<O`hjp pa"K*W.t.l@DEAEEEKKLLM\`Zaarb_cc|d;eecfMggmiknnnoooorss$s_szsssst t)t?tUt}ttttttuu\u]uiujuuuvv)v*vuvvvwuwyw Gҁ:/uИ$x֚ JRzVָܴ?KKqr!/W>R<_g &g6nN G"(())?)W)~))./4/g/~////0]01S667p7789:;;c<<=3=_====>>5>>>>?C????3@F@Y@m@@JQ5RRRT[def=gh2j)kkTmnpxρ;ߟPI!1D`IRdZ ;dDek)QPT./r[Cs,Gjr "$b%%&t&&''1'' ((((R))011 2G2233 556*8:=?ELPpW ]aamm v{"}̄h6Ϯ.=Ưۯg7#AiȶDik=һs`bcdnx      !"#$&'()*+,-./0123456789:;=>?@ABCDEFGHIJKLMNPQRSTUVWXYZ[\]^_abcdefgiklmnoqrstuvwxyz{|}~     am     6 @ \ ^ _ a    : = > @ ^ e :e D`cdf&Lhkln 0Gcfgi  .?[^_a3Njmnp   +7SVWYw&BEFHf">ABDbp "@Jfijl  ,=Y\]_}8;<>\h"%&(FTpstv   +5QTUWu$@CDFdr9<=?]v ),-/M\x{|~  ,?[^_a  , H K L N l !0!4!5!7!U!!!!!!!!"="A"B"D" $3$G$~~~)&))) SՎQwYސ (TΑ"S-),#tMtdtiuuuCviv|v{wwwRxyxxx%y?yyyzzzz{{{|||}~&~)EÃlg͆]U|$sNJ/el،bIn X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%X%̕X:_QXXXXXXXX_XXXXXXXXXXXXXXXXXXXXXXXX  #[!!P$ a\/X2$%82 #  "$Ů n? M܃M@R`M0Vc{M2C!M:9AD M{XMW1ʺ M(:@R`sX!fdD >%dV[sʺ jjW}%5Ofd<Z  S X?>2t" B s 8G HI&Bo_s1028"2$t" B s 8G HLI'o_s1029" ($t"  s 8G H\I9o_s1030"$t"  s 8G H/I`o_s1031"$t  s 8GߞHIߞ1_s10322'2(t   s 8GHI1_s1033 ('!((t   s 8GHI1_s1034}+,t   s 8GHI1_s1035'(n"   c 2HI1_s1036}+,n"  B c 2HמI1_s1037'(n" B c 2H )I1_s1038{} t  s 8GH HIH 1_s1039"6$qn  c 2GhHx Ih1_s1040 "q  bcp08cp081X)?_s10413"    ''   bcp08cp081X)?_s10423"        bcp08cp081X)?_s10433"   5$ ,   bcp08cp081X)?_s1044#"  - #   bcp08cp081X)?_s10453"   [$#'   bcp08cp081X)?_s10463"   H$"'   bcp08cp081X)?_s10473"   #$,'   bcp08cp081X)?_s10483"   ..$6'   b cp08cp081X)?_s10493"   q(}+    b cp08cp081X)?_s1050#"  ,`_/    b cp08cp081X)?_s10513"   ^(!}+    b cp08cp081X)?_s1052#"   ,M"_/    b cp08cp081X)?_s1053#"  #(n,}+    bcp08cp081X)?_s1054#"  D.(6}+ V - # -"+ V . # .", DB /  "DB 0  "DB 1  "DB 2  "DB 3  " DB 4  " DB 5  " DB 6  " DB 7  " DB 8  "DB 9  "DB :  "DB ;  "DB <  "DB =  "DB >  "DB ?  " DB @  "DB A  "#DB B  "'DB C  ")DB D  "(DB E  "&DB F  ""DB G  "DB H  "DB I  "DB J  "DB K  "DB L  "DB M  "6B N  DB O  "DB P  "DB Q  "DB R  "DB S  "!DB T  "$DB U  "%6B V  ~ W S NA?. T`TT`T*B S  ?     (  J   GhB#" ?<  #" ?<  #" ?J   Gz?#" ?J   G<#" ?J   G<#" ?')*++++++ ,%,&,',(,b,c,f,y,z,{,|,},~,,,,,,,---8-9-~--------- 7DڛHtt/88Dt:t9h ht08\8tVu RRt;t18>8~t6t5Xt4 t3X(t7(@(`t288t8HHtQ8b82 tLXXtK(htJ tI(t<tMX XtNt=tO)tPGgt>tR88tHht@tGh ht?tS88tFhtAtT8M8tU88tEhtBtD htCtWd$U@- qt.  t[[p upupu@u@u[@ uH _Hlt184006697 _Toc183751901 _Hlt184006685 _Toc183751902 _Toc183751903 _Toc183751904 _Toc183751905 _Toc183751906 _Toc183751907 _Toc183751908 _Toc183751909 _Toc183751910 _Toc183751911 _Toc183751912 _Toc183751913 _Toc183751914 _Toc183751915 _Toc183751916 _Toc183751917 _Toc183751918 _Toc183751919 _Toc183751920 _Toc183751921 _Toc183751922 _Toc183751923 _Toc183751924 _Toc183751925 _Toc183751926 _Toc183751927 _Toc183751928 _Toc183751929 _Toc183751930 _Toc183751931 _Toc183751932 _Toc183751933 _Toc183751934 _Toc183751935 _Toc183751936 _Toc183751937 _Toc183751938 _Toc183751939 _Toc183751940 _Toc183751941 _Toc183751942 _Toc183751943 _Toc183751944 _Toc183751945 _Toc183751946 _Toc183751947 _Toc183751948 _Toc183751949 _Toc183751950 _Toc183751951 _Toc183751952 _Toc183751953 _Toc183751954 _Toc183751955 _Toc183751956 _Toc183751957 _Toc183751958 _Toc183751959 _Toc183751960 _Toc183751961 _Toc183751962 _Toc183751963 _Toc183751964 _Toc183751965 _Toc183751966 _Toc183751967 _Toc183751968 _Toc183751969 _Toc183751970 `"`"v&4n8=E}o${~_ěhˡְͭ|Rֻc'o+`!_(s8B`FJL`gWjk l$xIN1/ϟѠP{5u ! 6UYlsێG@@  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFG `"h"&4u8=Eo-{~ۡ߰mrH;i!r(8ByFJL`gkjkl3xMT;:۟ߠ_A } !6UYlEsAmsvz<D 2 < t'|'q3w39999999:B:J:<<=!=]=f=g=u=??C@M@@@@@GARABB0B9BrB}B0C;C$D,DiDqDDDDDDDRGaGN%N^NhNNOOOOPPPPPPQ QQUUVVZVjVlVtVXX8Y?YrYzY\\\\\\]]/]9]N]U]o]z]]]____________8`A`I`N`````````/a;abbcclccccccc"d,dddeeneueeeeeeewf~fffShchii'i5i9iDi^ifiiiiikk9l=llmmmupp]qhqr#rrrrrsssssssstt]tgtCvJvNvXvvvvvvvVw_w{wwww:yAyyyyyyyy z zz{{||}}@~D~b~o~~~~~~~mt&.:hyDM(5T\ʊӊK\ƌό2>;DET׎ߎ>I5@ѐېܐ7BCLMQ\e‘ڑ?BCG]a ÕjlŞ˞ݞz}xˡ֡ܡ@MNUˢآ/:ʣ9F¤=HHPU^Z\jvwyͧϧĨШƩǩЩީ~hr̫֫LWͮ׮CP±ṉ̃%(NZ^f-34=T]¶%+58 146?FIKXͼڼz)(7:BCOWfr{,.ly:<5@O[48.2DHJVY`\ju '>]k|w<F$2=K&y\g|Y]SV`k(DOKV")EN UYBK*1CN @CS^$")blz{#1;EGQVa # 8 ; r    F O   1 ? (2ho $1ks+5ju(X_cj, /  !Z!d!!!!!%%%%%%%&5'='''K,X,,,-------.T._.`.m.{........%/2/q//////////!0&0000000/1=1^1i11122l2w222222222233-3.333c3q333333404:45"55566A66666D7R77777774:;:m:r:s:y:::;;h;s;t;;;;;;<<)=2=CCDD8ECEFFFF=HHHIIJJJJ4K;K=KFK_KgKKKNNtO{OQQQQQQQRoRzRGSQSSS7T:TTTUUclؿ8C !+Y` 2?EMOZKVgu  <DEOfqmz *7R_$,clq"+^j lv % D M t    H R   Wbfj '&*3FQ)24:;D/:Zev|RY *   _$e$g$o$s${$$$$%9%B%J%R%%%%%%%%%&"&J&T&&&B'O'''@(N((((((((()) )')))0)2);)f)o)~))))))))** *'*N*U*W*_***m+u+++++,,G-N-h-s-..///#/D/N/O/V///{00*101]1f1~11 22:2C222222233A3N3T3[3_3g3z33'63666667(7777788889(9::Z:f:::<<==>>>>??@@ACMCXFdFYIeIIINNOO]OfOpOzOOOOOP$P.P:PIPRPPPPPQQQQ&S2SNTZT_TkTaXlX-Y4YZZ.Z6ZKZQZZZZZZZZZ[[\\^^(^/^bbjj nnnnnnoooooooovp~pppppqqhrprrryrrrntwtttCuJuuuvvwwwwxxxxsz{z"|-|}}/}6}}}lqryR\t~́с؂܂ނ9AȄ؄@C*42;39}  ry(mv˜apsz'/nyLW)-â΢ -qxʦЦئ٦)/8>Gr{ħǧק47EPQ_`kluvèʨͨب6<`gөީ.FOhpʪ%6?]hyˬ¯įůϯүݯүݯ  @ _  > e eDdLlGg?_Nn 7W&F"Bp Jj =]<h&Tt 5U$Dr=v -\| ?_ , L !5!!!!"B"c"d"e"f"~~ ¯įůϯүݯޯvwwZ51W rVJI XgMN~c c&V  v -^t>b{w   znoA wu\Z  n!>~.z3X"  #P@ZKc'BsJm*@,2(* (+(HN+ y>+f"+-̲sTS. K.TP{/H*^%{f0Ξn32V2.k3 8/4 I81Z@O9.Rz-.:J+^nD;XX;\㸑}PW>@mt?k ,E DvF8ƪ{7IhsJ 0_.KXiK\JVLLftLvB-L PM|b0%qMF;M DO> YPXP+8Z:QUT,5Uz=)YZG e[2P{W\ aW] O]5X5d G{Fe2Fe~.gD gЛ(gp1xioFi .Aj/[Bj 8k^Q LkV^~jm 1*m@gTDmm m2,mD)GnH\er\-(}r2 Ctwu KPEws{6d5`|Tl* } TJa}8W hh^h`OJQJo( ^`OJQJo(  ^ `OJQJ^Jo(o   ^ `OJQJo( xx^x`OJQJo(HH^H`OJQJ^Jo(o ^`OJQJo( ^`OJQJo(^`OJQJ^Jo(o ^`OJQJo( hh^h`OJQJo(^`.^`.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L. hh^h`OJQJo( hh^h`OJQJo( 88^8`OJQJo(^`OJQJ^Jo(o   ^ `OJQJo(   ^ `OJQJo(xx^x`OJQJ^Jo(o HH^H`OJQJo( ^`OJQJo(^`OJQJ^Jo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo(hh^h`o(.hh^h`o()^`.^`.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L. hh^h`OJQJo( ^`OJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo( hh^h`OJQJo( ^`OJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo( hh^h`OJQJo( ^`OJQJo(^`OJQJ^Jo(o pp^p`OJQJo( @ @ ^@ `OJQJo(^`OJQJ^Jo(o ^`OJQJo( ^`OJQJo(^`OJQJ^Jo(o PP^P`OJQJo(^`.^`.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L. ^`OJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo( hh^h`OJQJo( ^`OJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo( hh^h`OJQJo( ^`OJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo( ^`OJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo( hh^h`OJQJo( ^`OJQJo(^`OJQJ^Jo(o pp^p`OJQJo( @ @ ^@ `OJQJo(^`OJQJ^Jo(o ^`OJQJo( ^`OJQJo(^`OJQJ^Jo(o PP^P`OJQJo( ^`OJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo( ^`OJQJo( pp^p`OJQJo(o @ @ ^@ `OJQJo( ^`OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( PP^P`OJQJo(o   ^ `OJQJo( ^`OJQJo(^`OJQJ^Jo(o pp^p`OJQJo( @ @ ^@ `OJQJo(^`OJQJ^Jo(o ^`OJQJo( ^`OJQJo(^`@$j@$j[fI  FMicrosoft Office Word Document MSWordDocWord.Picture.89q  Soar Valley Dental Practice_Z BASIC SYMPTOM Titlel& 8@ _PID_HLINKSA$&j_Toc183751951>(_Toc183751950>"_Toc183751949>_Toc183751948>_Toc183751947>_Toc183751946> _Toc183751945>_Toc183751944>_Toc183751943>_Toc183751942>_Toc183751941>_Toc183751940>_Toc183751939>_Toc183751938>_Toc183751937>_Toc183751936>_Toc183751935>_Toc183751934>_Toc183751933>_Toc183751932>_Toc183751931>_Toc183751930>_Toc183751929>_Toc183751928>_Toc183751927>_Toc183751926>_Toc183751925>_Toc183751924>_Toc183751923>_Toc183751922>z_Toc183751921>t_Toc183751920>n_Toc183751919>h_Toc183751918>b_Toc183751917>\_Toc183751916>V_Toc183751915>P_Toc183751914>J_Toc183751913>D_Toc183751912>>_Toc183751911>8_Toc183751910>2_Toc183751909>,_Toc183751908>&_Toc183751907> _Toc183751906>_Toc183751905>_Toc183751904>_Toc183751903>_Toc183751902>_Toc183751901՜.+,D՜.+,P  hp  Soar Valley Dental Practice_Z BASIC SYMPTOM Titlel& 8@ _PID_HLINKSA$&j%http://www.cafamily.org.uk/home.html 26http://www.ninds.nih.gov/disorders/disorder_index.htmF/< 0http://www.rarediseases.org/search/rdblist.htmlA 6http://www.helpthehospices.org.uk/education/index.asphy$http://www.palliative-medicine.org/?shttp://www.palliative.info//!http://book.pallcare.info/d0 http://www.palliativedrugs.com/9-http://www.gosh.nhs.uk/clinical_information/http://www.cnpcc.ca/>  http://www.childhospice.org.uk/*lhttp://www.act.org.uk/0,#http://www.greenbox.net/palliativeo+mailto:Dippallmed@velindre-tr.wales.nhs.uk>  http://www.childhospice.org.uk/*lhttp://www.act.org.uk/{ "mailto:mmiller@martinhouse.org.ukR/mailto:mcculr@gosh.nhs.uk`!mailto:susie.lapwood@bigfoot.comG,mailto:sat@jassal.f9.co.ukp mailto:HainRD@Cardiff.ac.ukK(mailto:CraigF@gosh.nhs.ukScmailto:p.carragher@chas.org.uk mailto:Lynda.Brook@RLC.NHS.UKUCAhttp://www.tso.co.uk/bookshop/bookstore.asp?FO=1160671&DI=352971T1http://www3.us.elsevierhealth.com/WOW/op020.html27http://www.stat.washington.edu/TALARIA/attachment.htmli:http://www.ich.ucl.ac.uk/cpap/Ahttp://www.ppprofile.org.uk/R_1http://www3.us.elsevierhealth.com/WOW/fyi03.htmlt8http://www.cancerpage.com/centers/pain/pediatrics_p.asp%http://www.iasp-pain.org/PCU95b.htmlG,mailto:sat@jassal.f9.co.uk>_Toc183751970>_Toc183751969>_Toc183751968>_Toc183751967>_Toc183751966>_Toc183751965>|_Toc183751964>v_Toc183751963>p_Toc183751962>j_Toc183751961>d_Toc183751960>^_Toc183751959>X_Toc183751958>R_Toc183751957>L_Toc183751956>F_Toc183751955>@_Toc183751954>:_Toc183751953>4_Toc183751952>.OJQJ^Jo(o PP^P`OJQJo( ^`OJQJo(^`.pp^p`.@ @ ^@ `.^`.^`.^`.^`.PP^P`. hh^h`OJQJo(88^8`OJQJ^Jo(o ^`OJQJo(   ^ `OJQJo(  ^ `OJQJ^Jo(o xx^x`OJQJo( HH^H`OJQJo(^`OJQJ^Jo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo( ^`OJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo( ^`OJQJo(^`OJQJ^Jo(o pp^p`OJQJo( @ @ ^@ `OJQJo(^`OJQJ^Jo(o ^`OJQJo( ^`OJQJo(^`OJQJ^Jo(o PP^P`OJQJo( ^`OJQJo(^`OJQJ^Jo(o pp^p`OJQJo( @ @ ^@ `OJQJo(^`OJQJ^Jo(o ^`OJQJo( ^`OJQJo(^`OJQJ^Jo(o PP^P`OJQJo( ^`OJQJo( pp^p`OJQJo(o @ @ ^@ `OJQJo( ^`OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( PP^P`OJQJo(o   ^ `OJQJo(^`o()^`.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L. ^`OJQJo(^`OJQJ^Jo(o pp^p`OJQJo( @ @ ^@ `OJQJo(^`OJQJ^Jo(o ^`OJQJo( ^`OJQJo(^`OJQJ^Jo(o PP^P`OJQJo( hh^h`OJQJo( ^`OJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo(^`. ^`OJQJo(pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L. hh^h`OJQJo( ^`OJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo( ^`OJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo( ^`OJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo( ^`OJQJo(^`OJQJ^Jo(o pp^p`OJQJo( @ @ ^@ `OJQJo(^`OJQJ^Jo(o ^`OJQJo( ^`OJQJo(^`OJQJ^Jo(o PP^P`OJQJo( ^`OJQJo( ^`OJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo( ^`OJQJo(^`OJQJ^Jo(o pp^p`OJQJo( @ @ ^@ `OJQJo(^`OJQJ^Jo(o ^`OJQJo( ^`OJQJo(^`OJQJ^Jo(o PP^P`OJQJo( hh^h`OJQJo( ^`OJQJo(^`OJQJ^Jo(o pp^p`OJQJo( @ @ ^@ `OJQJo(^`OJQJ^Jo(o ^`OJQJo( ^`OJQJo(^`OJQJ^Jo(o PP^P`OJQJo( 88^8`OJQJo(^`OJQJ^Jo(o   ^ `OJQJo(   ^ `OJQJo(xx^x`OJQJ^Jo(o HH^H`OJQJo( ^`OJQJo(^`OJQJ^Jo(o ^`OJQJo( ^`OJQJo(^`OJQJ^Jo(o pp^p`OJQJo( @ @ ^@ `OJQJo(^`OJQJ^Jo(o ^`OJQJo( ^`OJQJo(^`OJQJ^Jo(o PP^P`OJQJo( ^`OJQJo(^`OJQJ^Jo(o pp^p`OJQJo( @ @ ^@ `OJQJo(^`OJQJ^Jo(o ^`OJQJo( ^`OJQJo(^`OJQJ^Jo(o PP^P`OJQJo( 88^8`OJQJo(^`OJQJ^Jo(o   ^ `OJQJo(   ^ `OJQJo(xx^x`OJQJ^Jo(o HH^H`OJQJo( ^`OJQJo(^`OJQJ^Jo(o ^`OJQJo(^`.^`.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L.808^8`0o(.^`.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L. ^`OJQJo(^`OJQJ^Jo(o pp^p`OJQJo( @ @ ^@ `OJQJo(^`OJQJ^Jo(o ^`OJQJo( ^`OJQJo(^`OJQJ^Jo(o PP^P`OJQJo( hh^h`OJQJo( ^`OJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo( ^`OJQJo(^`OJQJ^Jo(o pp^p`OJQJo( @ @ ^@ `OJQJo(^`OJQJ^Jo(o ^`OJQJo( ^`OJQJo(^`OJQJ^Jo(o PP^P`OJQJo( hh^h`OJQJo( ^`OJQJo( pp^p`OJQJo(o @ @ ^@ `OJQJo( ^`OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( PP^P`OJQJo(o   ^ `OJQJo( ^`OJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo( ^`OJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo( ^`OJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo( ^`OJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo( ^`OJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo( hh^h`OJQJo( ^`OJQJo(^`OJQJ^Jo(o pp^p`OJQJo( @ @ ^@ `OJQJo(^`OJQJ^Jo(o ^`OJQJo( ^`OJQJo(^`OJQJ^Jo(o PP^P`OJQJo( ^`OJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo( ^`OJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo( ^`OJQJo(^`OJQJ^Jo(o pp^p`OJQJo( @ @ ^@ `OJQJo(^`OJQJ^Jo(o ^`OJQJo( ^`OJQJo(^`OJQJ^Jo(o PP^P`OJQJo( hh^h`OJQJo( ^`OJQJo(^`OJQJ^Jo(o pp^p`OJQJo( @ @ ^@ `OJQJo(^`OJQJ^Jo(o ^`OJQJo( ^`OJQJo(^`OJQJ^Jo(o PP^P`OJQJo( hh^h`OJQJo( ^`OJQJo( pp^p`OJQJo(o @ @ ^@ `OJQJo( ^`OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( PP^P`OJQJo(o   ^ `OJQJo( ^`OJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo( ^`OJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo(      ^`OJQJo(o PP^P`OJQJo( ^`OJQJo( pp^p`OJQJo(o @ @ ^@ `OJQJo( ^`OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( PP^P`OJQJo(o   ^ `OJQJo( ^`OJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo( ^`OJQJo(^`OJQJ^Jo(o pp^p`OJQJo( @ @ ^@ `OJQJo(^`OJQJ^Jo(o ^`OJQJo( ^`OJQJo(^`OJQJ^Jo(o PP^P`OJQJo(hh^h`o(. 88^8`OJQJo(L^`L.  ^ `.  ^ `.xLx^x`L.HH^H`.^`.L^`L. ^`OJQJo(^`OJQJ^Jo(o pp^p`OJQJo( @ @ ^@ `OJQJo(^`OJQJ^Jo(o ^`OJQJo( ^`OJQJo(^`OJQJ^Jo(o PP^P`OJQJo( ^`OJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo( ^`OJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo( ^`OJQJo(^`OJQJ^Jo(o pp^p`OJQJo( @ @ ^@ `OJQJo(^`OJQJ^Jo(o ^`OJQJo( ^`OJQJo(^`OJQJ^Jo(o PP^P`OJQJo( ^`OJQJo(^`OJQJ^Jo(o pp^p`OJQJo( @ @ ^@ `OJQJo(^`OJQJ^Jo(o ^`OJQJo( ^`OJQJo(^`OJQJ^Jo(o PP^P`OJQJo( hh^h`OJQJo( 88^8`OJQJo(^`OJQJ^Jo(o   ^ `OJQJo(   ^ `OJQJo(xx^x`OJQJ^Jo(o HH^H`OJQJo( ^`OJQJo(^`OJQJ^Jo(o ^`OJQJo(Z{W\ sTS.csJaW],mwu0_.KDvF{wI51Wc&V ~jmz3X" }DmmX5d N+ ,E;M2(*XX;G{Fem g(+\er+-VLL%{f0FiB-L/4rVPEw1*m Ct #nD;tLZ:Q.Ajt?DOZKc'LkP-.:{7IG e[XgMP>{zn325U}PW>wu YPUTJa}K.v 5`|O]=)Y0%qM)GniK[Bj-^t.gY&yP{/ I81xi(gsJm*k}rs+@O9PMek3H($ ~ZZ                                                                                                                                                                                                                                                                                                                                                                        T                                                                                                                                                                                            $                                                              9<<<<<<<<<<===="='=9=A=\=]=g=v=}=====\C}C~CCCCCCCCCCCCD DDDDD}DDDDEEXXXXXXXXZY[Y{YYYZZGZrZsZZZ_[`[[[[[[[[[[[|\}\\\\;]<]V]b]|]]]]]^c^d^^^_M_N_q_r_w______!`I`manaffffffffffffffffffffgg g ggggggggbjjjjjjjjjjjjkkkkkkk$k+k1k8kAk_k`kfkkkzkkkkkkkkkkkkkkkkllll l!l"l)l0l1l3l>l?l@lUlZldlmltl|l}l~llllllllllllllllllllm m m m mmmmm'm2m5m7m8m\m]m^m_mbmemfmgmhmimjmymmmmmmmmmmmmmmmnnnnn%n&n'n(n)n*n:n?nQnqnsntnunvnnnnnnnnnnoohosotouovoxxxxxx y y y y!y/y0y1yByGyyyyyyyyyyyyyyyyy zzVz^zzzzz{!{"{Sz|ϐАѐ$+67\fxڑhijoy֒גْؒ !*/AHJK KLMNbpqr|#+pqr %PQRSguvw ;<GLnv{|<=LQ_~&'(38Zbghpuv~67FK`anopqr|X              !!)!*!,!-!.!/!>!?!A!B!C!D!V!W!Y!Z!j!o!w!|!~!!!!!!!!&&&&&&''''%'3'4'5'>'C'U'c'g'h'i'j'|'}'~''''''''''''''''''((((((+(,(-(.(F(L(](^( .8.9.>.M.S.T.`.{.....//%/@/p/q//////-000001112222233.3@33333c4d44444444445555#5(5)5/5354555A5T5_5`5o5t5555555555555555555556 6 6 666666636465666C6H6m6u6666666666666666777(7C7D7S7X7b777777777777777888838485868D8E8F8G8H8I8W8X8Y8Z8[8\8k8l8m8n8>I?IIIIIIII5J6JQJ`JJJJJJJ\\\\\\=]]^^*__``ab$b)b2b3bVbbCcDcSccdd#ddTeUe`efgg}~ !",12@DE\`a$%&';IJKWf ,-./AF[afgv{'VWXY*?   .7;<EJU`deot|9DEPUaefrwFGHI]klm)*8=?HQR`eoz!#$KP`tuJOTUV"&*./OT\dlt|  0[\]^r    ' , w                            & + 2 7 C D N S ^ s t                           * + , - . / E F G H S X Y ^ j k 7bcdey"Btuv} /012gn        + D b f          !!!!!R(}(~((((((((()))=)[)))))) * **(*F*G*H*N*`*******++˦ϦЦ*./9=>HƧǧاۧܧҭ߭      !"#$%&',-./0123456789:;<=>?@ABCDESTUVWXYZ[\]^_`abcdefghijkl®îĮŮƮǮȮɮڮۮܮݮޮ߮     ,-./0123456789:;<=>?@ABCDEPQRSTUVWXYZ[\]^_`abcdefghiyz{|}~įxZ@ =@@Unknown Gz Times New Roman5Symbol3& z ArialWCalibriTimes New RomanI& ??Arial Unicode MS?5 z Courier NewA& Arial Narrow5& zaTahoma;Wingdings"0hrA¦rA¦bfI[_fI[_4dZZ2QHX ?92Z BASIC SYMPTOM JassalWitstZ                           ! " # $ % & ' ( ) * + , - . / 0 1 2 3 4 5 6 7 8 9 : ; < = > ? @ A B C D E F G H I J K L M N O P Q R S T U V W X Y