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HIVNutritionEssentialsForProgramandAdministrativeGranteesMarcyFenton,M.S.,R.D.ProgramManager,CareServicesDivisionCountyofLosAngelesDepartmentofPublicHealthOfficeofAIDSProgramsandPolicyAugust29,2006LosAngelesCountySquareMiles:4,086Population:9.9MillionLatino/a45.7%White31.0%Asian/PI13.2%African-American 9.7%NativeAmerican0.3%ProportionofCaliforniaPopulation:29%ProportionofCaliforniaAIDSCases:35%LivingwithHIV/AIDS:58,000(Estimated)2 SPA 6:South SPA 8:South Bay SPA 5:West SPA 2:San Fernando SPA 4:Metro SPA 3:San Gabriel SPA 1:Antelope Valley SPA 7:East 2HIVNutritionEssentialsOverviewCurrentnutritionissuesandtreatmentsMedicalnutritiontherapy(MNT)programnecessaryingredientsLessonslearnedmonitoringLosAngelesCountymedicaloutpatientservicesMNTprograms3HIVNutritionEssentialsHandoutMaterialsPresentationslidesGuidesandresourcesDiet,nutrition,factsheetsProfessionalcompetencyWeight&nutritionHIVnutritionscreen&referralformsADA2005NutritionquickscreenRequest copies of handouts:4HIVNutritionEssentialsCurrentHIVNutritionIssues5HIVMNTOverallGoalsOptimizenutritionstatus,immunityandqualityoflifePreventnutrientdeficienciesAchieveandmaintainoptimalbodyweightandcompositionManageco-morbiditiesMaximizeeffectivenessofmedications6ViciousCycleofMalnutritionandHIVPoor Nutrition resulting in weight loss,muscle wasting,weakness,nutrient deficienciesIncreased Nutritional needs,Reduced food intake and increased loss of nutrientsIncreased vulnerability to infections e.g.Enteric infections,flu,TB hence Increased HIV replication,Hastened disease progression Increased morbidityImpaired immune system Poor ability to fight HIV and other infections,Increased oxidative stressHIVSource:Fanta Project Adapted from RCQHC and FANTA 20037HIVNutritionIssuesPoorImmuneFunctionFoodandwatersafety,sanitationOptimizednutrientandfluidintakeVitaminmineralsupplementationExercise:aerobicandprogressiveresistancetrainingMedicationadherenceStressreductionEstablishmentoftrustingrelationships8NutritionIssuesandTreatmentsCommonSideEffectsGIdistressDiarrheaNausea/vomitingGasAnorexiaFatigueTastealterationsMouthpainAnemiaHyperlipidemiaInsulinresistanceHypertensionLivertoxicityRenalimpairmentObesityLipodystrophyPeripheralneuropathyCancer9CausesofWeightLoss1-InadequateIntakeOralanduppergastrointestinalAnorexiaPsychosocial-economicMalabsorptionSource:MangiliAetal.CID2006:42(15March)p836-4210CausesofWeightLoss2-AlteredMetabolismUncontrolledHIVinfectionMetabolicdemandsofHAARTOpportunisticinfectionsormalignancies(AIDS-definingconditions)Hormonaldeficiencies(testosteroneorthyroid)CytokinedysregulationSource:MangiliAetal.CID2006:42(15March)p836-4211RestingEnergyExpenditureGrunfeldetal.AJCN1992;55:455-60.12ImpactofViralLoadonRestingEnergyExpenditure13HIVWastingDefinitionsCDCNutritionforHealthyLiving(Tufts)Grinspoon,Mulligan&DHHSWorkingGroupPolsky,Kotler&Steinhart14CaloriesNeededandWeightChangeRelationtoViralLoadNotonHAART0.92kgbodyweightdecreasepereachHIVRNAlog10increase22KcalincreaseinREEperincreaseinper1-logcopy/mlStableHAART0.35kgbodyweightdecreasepereach100-cell/mm3CD4celldecrease81kcalhigherREESource:Wanke et al.CID 2006:42(15 March)15OutcomesofWeightLossMorbidityandmortalityindependentofCD4andviralloadWeightlossof5%associatedwithincreaseriskofmortalityevenwithARTAdversepregnancyoutcomesWeightloss&wastingcontinuetobecommonproblems16InternationalNutritionFeedingSafelyandAdequatelyAccesstonutritiousfoodAccesstosafewaterMalnutritionLinkedwithHIVinfectionLinkedwithpoorprognosisLinkedwithpoorprognosisdespiteARTBreastfeedingAccesstoHIVmedications17Overweight,ObesityandHIVSources:(1)Amorosaetal.JAIDS2005;Aug15;39(5):557-61.(2)NHANES1999-2000;7/0318WeightClassificationUsingBMIBMI1NoteUnderweight18.5Malnutrition218.5Wasting340.0(1)NationalHeart,LungandBloodInstitute,(2)Magilietal.CID2006March,(3)Amorosa;Grinspoon,Mulligan&DHHSWorkingGroup2003April-SCID19ConditionsAssociatedwithObesityObesityHyperlipidemiaHeartDiseaseStrokeHypertensionGoutNon-InsulinDependentDMOsteoarthritisMoodDisordersSleepDisordersEatingDisordersSomeCancersGallBladderBMI:HIVvs.GeneralPopulationsContemporaryDiagnosisandManagementofObesity.GerogeA.Bray,MD20DesirableGirthMeasurementsWaistcircumferenceMen:40inchesWomen:35inchesNHANESmethodologyWaisttoHipRatio?LessaccurateNotrecommendedHipcircumferenceokMonitorwaist&hipfrombaseline21Overweight,Obesity&HIVFuelofMetabolicAbnormalitiesBMIpositivecorrelationwithTotalcholesterolTriglyceridesGlucoseObesitynotcorrelatedwithAge,income,employment,educationPast/currentIVDuseHIVtreatment,viralloadSource:Amorosaetal.JAIDS2005;Aug15;39(5):557-61.22TreatmentofObesityTherapeuticLifestyleChangesNutritioncounselingDietaryintakeLimitsaturatedfatsIncreasefiberto35g/dayPortioncontrolReduceexcesscarbohydratesandhighsugardrinksPlentyoffruitsandvegetablesSmallmeals:maximum5hoursapartEatslowly23TreatmentofObesityTherapeuticLifestyleChangesPhysicalactivityWalkingorotherexercise30-60minutes/dayProgressiveresistancetraining24HIVandDiabetesMellitusAnIncreasingHIVNutritionProblemHIV-positivemenwhoaretakinghighlyactiveantiretroviraltherapy(HAART)aremorethanfourtimesmorelikelytodevelopdiabetesthanHIV-negativemen.HIV-positivewomentakingproteaseinhibitorsarethreetimesmorelikelytodevelopdiabetesthanHIV-positivewomenonnon-proteaseinhibitorcombinationsorHIV-negativewomenSources:BrownTTetal.Antiretroviral therapy and the prevalence and incidence of diabetes mellitus in the Multicenter AIDS Cohort Study.ArchInternMed165:1179-1184,2005.JustmanJEetal.Protease inhibitor use and the incidence of diabetes mellitus in a large cohort of HIV-infected women.JournalofAcquiredImmuneDeficiencySyndromes,32:298302,200325DiabetesMajorRiskFactorsGeneralPopulationOverweight,obesityEspeciallyVATParentorsiblingEthnicityAlaskaNative,AmericanIndian,AfricanAmerican,LatinoAmerican,AsianAmericaInactivityExercisevisceraladiposetissuePhysicalinactivityNeuropathy,fatigueavascularnecrosis,wasting,etc.27HeartDiseasePrevalenceGeneralPopulationLeadingcauseofdeathintheU.S.Women:51%ofheartdiseasedeathsMen:340,933diedfromheartdiseasein200257millionAmericanslivewithCVD8.9%allwhitemen7.4%blackmen5.6%MexicanAmericanmen1.NationalCenterforHealthStatistics.Health,UnitedStates,2005withChartbookonTrendsintheHealthofAmericans.Hyatsville,MD:2005.2.AmericanHeartAssociation.HeartDiseaseandStrokeStatistics2005Update.Dallas,Texas:AmericanHeartAssociation,2005.28HeartDiseaseMajorRiskFactorsGeneralPopulationIncreasingageGenderHeredity,familyhistoryofprematureheartdiseaseOverweight/obesityHighbloodpressureTobaccouseHyper-ordyslipidemiaEspeciallyhighLDL&lowHDLDiabetesMetabolicsyndromePhysicalinactivityPoornutritionAnatherogenicdietSource:Preventingchronicdiseases:Investingwiselyinhealthpreventingheartdiseaseandstroke.July2005.CDC.February6,2006.29HeartDiseaseRiskFactorsHIVPopulationInflammationduetoHIVLipidabnormalitiesduetoHAARTOtherdrugeffects:InsulinresistanceMorphologicalchangesMetabolicsyndrome30HeartDiseasePrevention&TreatmentTherapeuticLifestyleChange(TLC)DietPhysicalexerciseManagementofconcomitantdiseasesDiabetes,hypertension,obesity,etc.SmokingcessationStressreduction31LiverDiseaseFueledbyOverweight&ObesityWaisthip,insulinresistance&diabetesPredictsadvancedformsofchronichepatitisCComplicatesnonalcoholicsteatohepatitis(NASH)FitnessinverselyrelatedTx:Healthydiet,exercise,weightlossSources:CharltonMRetal.HepatologyJune2006;46(6)1177-1186;ChurchTSetal.Gastroenterology.2006Jun;130(7):2023-2030.32RenalDiseaseandHIVAGrowingNutritionProblemDialysisHIV:1.5%,AIDS:0.4%DialysiscenterstreatingPLWH/A1985:11%2000:37%Numberinitiatedsince1995:stableAbnormalkidneyfunction30%PLWH/AHIVandCKDnutritionguidelinesNotsetyetIndividualize33HIVNutritionEssentialsMedicalNutritionTherapy(MNT)ProgramNecessaryIngredients34ContinuumofCareCountyofLosAngeles.ContinuumofCare,OfficeofAIDSProgramsandPolicy.35HIVRegisteredDietitianStandardsofProfessionalPracticeProvidesqualityservicebasedonclientexpectationsandneedsEffectivelyapplies,participatesinorgeneratesresearchtoenhancepracticeEffectivelyappliesknowledgeandcommunicateswithothers36HIVRegisteredDietitianStandardsofProfessionalPracticeUsesresourceseffectivelyandefficientlyinpracticeSystematicallyevaluatesthequalityandeffectivenessofpracticeandrevisespracticeasneededtoincorporatetheresultsofevaluationEngagesinlifelongself-developmenttoimproveknowledgeandenhanceprofessionalcompetence37HIVRegisteredDietitianCareResponsibilityCreatescreeningtoolsformedicalproviderstoidentifyclientsatriskMonitornutrition-relatedabnormallaboratoryvaluesAssessclientsregularly,consistentlyEnsureadequatenutrient&caloricintake38HIVRegisteredDietitianCareResponsibilityWithmedicalteam,identifyandcorrectcausesofcachexia,weightloss/gain,othernutritionproblemsandbarriersRefertoprovidersandotherdisciplinesCommunicate:document,speak,shareParticipateinteamcaseconferencesPromotecontinuityofcare39 Relationship Between Patient/Client/Group&Dietetics Professional -Nutrition Diagnosis Identify and label problem Determine cause/contributing risk factors Cluster signs and symptoms/defining characteristics Nutrition Assessment Obtain/collect timely and appropriate data Analyze/interpret with evidence-based standards Identify risk factors Use appropriate tools and methods Involve interdisciplinary collaboration Screening&Referral System Outcomes Management System Monitor the success of the Nutrition Care Process implementation Evaluate the impact with aggregate data Identify and analyze causes of less than optimal performance and outcomes Refine the use of the Nutrition Care Process ADA NUTRITION CARE PROCESS AND MODEL Document Nutrition Monitoring and Evaluation Monitor progress Measure outcome indicators Evaluate outcomes Document Nutrition Intervention Plan nutrition intervention Formulate goals and determine a plan of action Implement the nutrition intervention Care is delivered and actions are carried out Document Document NCP40ScreeningandReferralScreenforReferralCriteriaNew/re-entryintocare,MNT6monthsMedicaldiagnosis,nutritionstatuschangePhysicalchanges,weightconcernsOral,GIsymptomsMetabolic,othermedicalconditionsBarrierstonutrition,livingenvironment,functionalstatusBehavioralconcerns,unusualbehaviorsSource:ADAMNTEvidenceBasedGuidesforPractice,March200541ScreeningandReferralReferralDocumentationPhysiciansorderforMNTSignatureanddateofphysicianorauthorizedpersontoreferforMNTMedicaldiagnosesandinformationCurrentlabsandmeasurementsConsenttoreleasemedicalinformationProof of residency,income,diagnosisSource:ADAMNTEvidenceBasedGuidesforPractice,March200542NutritionCareProcessADIMENutritionAssessmentNutritionDiagnosisNutritionInterventionNutritionMonitoringNutritionEvaluationDocumentation:clearandexplicit43NutritionCareProcessNutritionAssessmentReasonforreferralAssessdata(ABCD)AnthropometricBiochemistryClinicalDietaryClientinput44NutritionCareProcessNutritionDiagnosisProblemDiagnosticlabelIntake,clinical,orbehavioral/environmentalEtiologyCauseorcontributingriskfactorsSigns/SymptomsDefiningcharacteristicsPESstatement45NutritionCareProcessNutritionDiagnosisPESStatement(P)Increasednutrientneeds(E)asrelatedtoinadequateintakeoffoodsandmalabsorptionduetoAIDSenteropathy(S)asevidencedby25poundweightlossin6monthsandnow91%IBW46NutritionCareProcessNutritionInterventionInterventionsFoodand/orNutrientDeliveryNutritionEducationNutritionCounselingCoordinationofNutritionCareReceptivityandadherencepotentialPlanandfollow-update47NutritionCareProcessNutritionMonitoringReviewandmeasurestatusofinterventionatscheduledtimeTrackoutcomeswithtoolsADAHIVMNTProtocolProgressNoteWeightandnutritionflowsheetElectronichealthrecorddatafieldsFormatTerminology:diagnosis,interventions,etcOthertools48NutritionCareProcessNutritionEvaluationSystematiccomparisonsReferencestandardsEvaluatechangesSignsandsymptomsPreviousstatusandinterventiongoalsProgresstowardgoal49HIVMNTToolsBasicsHIVMNTProtocols(ADA,1998)Adult(18years-adult)Children(under18years)Health Care and HIV:Nutritional Guide for Providers and Clients(HRSA/HAB,2002)IntegratingNutritionintoMedicalManagementofHIV,(CID-SApril12003)Nutritioninterventioninthecareofpersonswithhumanimmunodeficiencyvirus.(ADA&DietitiansofCanadaJointPosition,2004)50HIVMNTToolsNew:ADAEvidenceAnalysisLibrarySystematicreviewofscientificresearchSelecttopicandexpertworkinggroupDefinequestions,analyticalframework,inclusionandexclusioncriteriaConductliteraturereviewperquestionAnalyzearticlesCompleteevidencesummariesandtablesDraftproposedconclusionstatementsReachconsensusonconclusionstatementsandgrades(strengthandqualityoftheevidence)Publishtoonlinelibrary(EAL)51HIVMNTToolsNew:ADAEALCurrentProjectsDiseasesandconditionsAdultweightmanagementDeterminantsofpediatricoverweightChronickidneydisease(revision)ChronicobstructivepulmonarydiseaseCriticalillnessDisordersoflipidmetabolism(hyperlipidemiarevision)52HIVMNTToolsNew:ADAEALCurrentProjectsDiseasesandconditions(cont.)GestationaldiabetesGlutenintolerance/CeliacHeartfailureHIV/AIDSHydrationHypertension53HIVMNTToolsNew:ADAEALCurrentProjectsDiseasesandconditions(cont.)NutritioninathleticperformanceNutritioncareinbariatricsurgeryOncologyPediatricweightmanagementSpinalcordinjury&nutritionUnintendedweightloss54HIVMNTToolsNew:ADAEALCurrentProjectsAssessmentEstimatingenergyexpenditureFoodsNon-nutritivesweetener55HIVMNTToolsEmerging:HIVNutritionEvidenceAnalysisQuestionsWhatarethecaloricneedsofpeoplewithHIV/AIDS?WhatistheevidencetosupportaparticularmacronutrientcompositionofadietforpeoplewithHIV/AIDS?FocusBothchildrenandadultsPeoplewithHIV/AIDSPast10yearsofresearch56HIVMNTToolsNewandEmergingNutritionCareManualWebbasedUses ADAEvidenceAnalysisLibraryEvidence-basedMNTprotocolsEvidence-basedguidelinesADApositionpapers57ReimbursementMNT,SupplementsMedicareMedicaidManagedCareHMOs,KaiserPermanenteRWCA58PersonalProfessionalCompetenceDieteticsProfessionalsEthicalObligationCode of Ethics for the Profession of Dietetics,(6)Standards of Professional Practice,(7)GuidedbythenutritioncareprocessProfessional Development Portfolio(8)75creditseveryfiveyears59RyanWhiteCAREActandMNTCurrentStatusMNTbyRDDefinedbyHRSAguidanceRequiredinTitleIIIservicesRWCAreauthorizationExpectedafterLaborDay2006ADAandothersworkingtogetMNTascoremedicalserviceAIDSEducationTrainingHIVnutritiontrainingforproviders60CurrentProceduralTerminologyMNTCPTCodes97802Initialassessmentandintervention,individual,face-to-facewiththepatient,each15minutes97803Re-assessmentandintervention,individual,fact-to-facewiththepatient,each15minutes97804Group(2ormoreindividuals),each30minutes61HIVNutritionEssentialsLessonsLearnedMonitoringLosAngelesCountyMedicalOutpatientServicesMNTPrograms62MonitoringHIVMNTServicesMNTProgramEvaluationItemsScreeningfornutritionrelatedproblemsReferralforbaselineMNT(06-07)AppropriatereferralforMNTMNTprovidedbyanRDMNTdocumentation(05-06)Outcome:maintainor5%towardsgoalweightafter3monthsofcare(07-08)RDqualifications6329(.8,0-10)2(.1,0-1)Screened77(2.1,0-8)38(1,0-4)ReferraltoMNT66(1.8,0-6)32(.9,0-5)MNTProvided62n/aMNTQuality244(6.8,4-10)154(4.3,2-8)ChartsReviewed(average,range)3636Sites(of37)16,48716,143Clients(1visit)Yr 15 2005-2006Yr 14 2004-2005MonitoringMNTPrograms64RD Availability2004-20052005-2006Clinics,number3737Onsiteday/month2832Referraloffsite45Noneavailable50AccesstoMNT65ChangingPracticesandAttitudesEstablishingtheFrameworkforMNTWheelsofchangemoveslowlyDevelopinfrastructureStandardsofcare,guidelines,contractsIndicators,monitoringtools,reportsMNTservices:disparityinclinicsProviders,programmanagers,fundingAwareness,interpretationandabilitiesExpectations,goalsetting,reporting,access66ChangingPracticesandAttitudesTechnicalAssistance:ProvidersandRDsProvidermeetings,calls,emailsProviderandstaffpresentationsAteachyearsprogrammonitoringDifferentandevolvingTAfocusAlwaysprovidematerialsEx:HRSANutritionManualCD,screening&referralforms,articles,standardsofcare,BMIchart,nutrition&weightflowchart67ChangingPracticesandAttitudesTechnicalAssistance:RDSDietitiansinAIDSCare(DIAC)DIAClistserveQuarterlymeetingssinceApril2005Networkinglong-lastingrelationshipsTrainingandproblemsolvingNutritioncareprocessWhentoprovide/discontinue:nutritionalsupplements,food/mealservicesHyperlipidemia,insulinresistance,renaldisease68PersonalGrowthLessonsLearnedMoremedicalrecordsreviewedMonitoringtools-streamlinedandtally/commentssheetsIncreasetimespentmonitoringEvaluationreportofMNTprogramsEstablishongoingdatabaseBaselineknowledgeofprograms69ScreeningforNutritionProblemsLessonsLearnedNewtonslawsofmotionProvidersresistanceProblems?DontlookandyouwontfindScreeningvs.referringDefining“atrisk”Makeiteasytolook,think,documentSimplequestionswork70HeightandWeightMeasurementsLessonsLearnedRoutinemeasurementsneededHeightnotalwaysmeasuredWeightusuallymeasuredAccuracyquestionableonbothWhomeasures?Howtrained?Shoes?Calibrationofscales?Stadiometer?MonitoringweightAdding/subtractingusuallynotdoneBMInotusuallydoneGraphingnotdone71ReducingBarrierstoMNTLessonsLearnedReducingbrokenappointmentsSetappointmentswithclientCoordinatewithprimarycarevisitRemindersandfollow-upcallsandlettersDocumentinmedicalrecordSupportMNTinclinicInclude,discussandreferralfromstartIncentivesandrewardsforMNTvisitAsk/respondtoclientrequestforMNT72Needed:ProactiveHealthyClinicLessonsLearnedTakeresponsibilityandpowerEducate&supportstaff:promote:NutritionandhealthknowledgeClientsfood,nutrientandsafetyneedsChangethemenuandfood/watersafetypracticesforclientandnon-clienteventsMeetings,parties,fundraisers,vendingmachines,vouchers,boardmeetings,holidays,etc.73HIVNutritionEssentialsWhathasbeenyourexperience?Whathasworkedwell?Whathasbeenachallenge?74AcknowledgmentsArcyMartinezRDAltaMedHealthServicesCorporationAudraGustafsonRDNortheastValleyHealthCorporationTammyDarkeMSRDStMaryMedicalCAREProgramJillStrejcMSRDSRDUCLACarenOngjocoRDCNSDLosAngelesCountyHarbor-UCLAMedicalCenterJanBKingMDMPHOAPPMedicalDirector75MarcyFenton,M.S.,R.D.ProgramManager,CareServicesDivisionOfficeofAIDSProgramsandPolicy600SouthCommonwealthAvenue2ndFloorLosAngeles,California90005-4001Phone:213/351-8368Fax:213/738-6566E-mail:ThispresentationisavailableatForAdditionalInformationoWlTiQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVjSgPdLaI7F3C0y)v&s#pXmUiRfNcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgOdLaI6F3C0y)v%s#pXlUiRfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4C1z-w&t!qYmVjRgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkShPeMaJ7G4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8G5D2A-x*u$qZnWkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-w*t$qYnVkSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgPdLaI6F3C0y)v&s#pXlUiRfNcK9H5E2A+x(u$rZoWkThPeMbJ7G4D1z-w&t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5E2A+x*u$rZnWkThPeMaJ7G4C1z-w&t!pYmVjRgOdL9I6E3B0y(v%s#oXlTiQfNbK8H5D2A-x*u$qZnWkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9I6E3B+y(v%r#oXlTiQeNbK8G5D2A-x*t$qZnVkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F3C0zr#oXlTiQeNbK8G5D2A-x*t$qZnVkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlTiQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+x(u%rZoWlThQeMbJ8G4D1A-w*t!qYnVjSgPdLaI7F3C0y)v&s#pXmUiRfNcK9H5E2B+x(u$rZoWkThQeMbJ7G4D1z-w*t!qYmVjSgOdLaI6F3B0y)v%s#pXlUiQfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4C1z-w&t!qYmVjRgOdL9I6F3B0y(v%s#oXlUiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmUjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8G5D2A-x*u$qZnVkShPdMaJ7F4C0z)w&s!pYmUjRfOcL9H6E3B+y(u%r#oWlTiQeNbJ8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVjSgPdLaI7F3C0y%r#oWlTiQeNbK8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVjSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgOdLaI6F3C0y)v%s#pXlUiRfNcK8H5E2A+x(u$rZoWkThPeMbJ7G4D1z-w&t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkShPeMaJ7G4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%s#oXlTiQfNbK8H5D2A-x*u$qZnWkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1A-x*t$qZnVkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-w*t$qYnVkSgPdLaI7F3C0z)v&s#pXmUiRK8G5D2A-x*t$qZnVkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlThQeNbJ8G5D1
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